Provider Demographics
NPI:1891516068
Name:DE LA VEGA, PRISCILLA
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:DE LA VEGA
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 1:4366 BERMUDA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-5040
Mailing Address - Country:US
Mailing Address - Phone:951-686-6266
Mailing Address - Fax:
Practice Address - Street 1:4366 BERMUDA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-5040
Practice Address - Country:US
Practice Address - Phone:951-686-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker