Provider Demographics
NPI:1649514480
Name:DELILLE, MYRLANDE (PA)
Entity type:Individual
Prefix:
First Name:MYRLANDE
Middle Name:
Last Name:DELILLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MYRLANDE
Other - Middle Name:
Other - Last Name:VERNEUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:795 FLUSHING AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-4107
Mailing Address - Country:US
Mailing Address - Phone:718-387-7300
Mailing Address - Fax:718-387-9700
Practice Address - Street 1:795 FLUSHING AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-4107
Practice Address - Country:US
Practice Address - Phone:718-387-7300
Practice Address - Fax:718-387-9700
Is Sole Proprietor?:No
Enumeration Date:2012-11-17
Last Update Date:2012-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002600-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant