Provider Demographics
NPI:1083439558
Name:LADELFA, DESEREA (BA, PBT(ASCP))
Entity type:Individual
Prefix:
First Name:DESEREA
Middle Name:
Last Name:LADELFA
Suffix:
Gender:F
Credentials:BA, PBT(ASCP)
Other - Prefix:
Other - First Name:D.G.
Other - Middle Name:
Other - Last Name:LADELFA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:123 BENTON AVE
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-4153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 BENTON AVE
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-4153
Practice Address - Country:US
Practice Address - Phone:478-219-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70367246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty