Basic Information
| Provider Information | |||||||||
| NPI: | 1366811838 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELVALLE | ||||||||
| FirstName: | COLLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4575 SE DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349976826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Practice Location | |||||||||
| Address1: | 10850 S US HIGHWAY 1 STE 2 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349526407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724630444 | ||||||||
| FaxNumber: | 7722191339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2015 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | FL | N | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 106E00000X | Y |
No ID Information.