Healthcare Provider Details

I. General information

NPI: 1710278346
Provider Name (Legal Business Name): MARC B DELISLE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2011
Last Update Date: 04/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7660 E MCKELLIPS RD LOT 80
SCOTTSDALE AZ
85257-4624
US

IV. Provider business mailing address

7660 E MCKELLIPS RD LOT 80
SCOTTSDALE AZ
85257-4624
US

V. Phone/Fax

Practice location:
  • Phone: 480-214-5401
  • Fax: 480-214-5401
Mailing address:
  • Phone: 480-214-5401
  • Fax: 480-214-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN117104
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN117104
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: