Provider Demographics
NPI:1063756732
Name:DELAVALLADE, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DELAVALLADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-5646
Mailing Address - Country:US
Mailing Address - Phone:504-885-4867
Mailing Address - Fax:504-836-2943
Practice Address - Street 1:4501 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-5646
Practice Address - Country:US
Practice Address - Phone:504-885-4867
Practice Address - Fax:504-836-2943
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist