Provider Demographics
NPI:1366178691
Name:DELVALLE, MIQUIA
Entity type:Individual
Prefix:MS
First Name:MIQUIA
Middle Name:
Last Name:DELVALLE
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 1:132 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-3968
Mailing Address - Country:US
Mailing Address - Phone:609-394-8988
Mailing Address - Fax:609-599-1561
Practice Address - Street 1:132 PERRY ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-3968
Practice Address - Country:US
Practice Address - Phone:609-394-8988
Practice Address - Fax:609-599-1561
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0102903Medicaid