Provider Demographics
NPI:1972324341
Name:DELVECCHIO, MIA LOUISE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:LOUISE
Last Name:DELVECCHIO
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 1:141 W 22ND ST STE 109
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:141 W 22ND ST STE 109
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4315
Practice Address - Country:US
Practice Address - Phone:765-646-8538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-18
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
IN10004684A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant