Healthcare Provider Details

I. General information

NPI: 1912976879
Provider Name (Legal Business Name): AMY L DELEVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 W FOREST AVE STE 304
FLAGSTAFF AZ
86001-1479
US

IV. Provider business mailing address

77 W FOREST AVE STE 304
FLAGSTAFF AZ
86001-1479
US

V. Phone/Fax

Practice location:
  • Phone: 928-214-3600
  • Fax: 928-214-3601
Mailing address:
  • Phone: 928-214-3600
  • Fax: 928-214-3601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34062
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: