Healthcare Provider Details

I. General information

NPI: 1508324583
Provider Name (Legal Business Name): DELVIA GEORGE VATHIELIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W BROWARD BLVD
FORT LAUDERDALE FL
33312-1638
US

IV. Provider business mailing address

1700 NW 49TH ST STE 125
FORT LAUDERDALE FL
33309-3750
US

V. Phone/Fax

Practice location:
  • Phone: 954-527-6041
  • Fax: 954-527-6052
Mailing address:
  • Phone: 954-527-6041
  • Fax: 954-527-6052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11000422
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11000422
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: