Provider Demographics
NPI:1962947242
Name:DE LA ROSA, DALAILAH REYNA (AGNP)
Entity type:Individual
Prefix:
First Name:DALAILAH
Middle Name:REYNA
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR
Mailing Address - Street 2:STE 400
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:305-500-2027
Mailing Address - Fax:305-500-2155
Practice Address - Street 1:4254 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-2469
Practice Address - Country:US
Practice Address - Phone:361-853-4191
Practice Address - Fax:361-853-8768
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2021-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132792363LA2200X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty