Healthcare Provider Details

I. General information

NPI: 1144603721
Provider Name (Legal Business Name): MARISLENE DELVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12206 MORANG DR
DETROIT MI
48224-1543
US

IV. Provider business mailing address

12206 MORANG DR
DETROIT MI
48224-1543
US

V. Phone/Fax

Practice location:
  • Phone: 313-458-2203
  • Fax: --
Mailing address:
  • Phone: 313-458-2203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007382
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number018640-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9108647
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: