Healthcare Provider Details

I. General information

NPI: 1851023410
Provider Name (Legal Business Name): GENESEE MAYLEE VILLALTA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY DR
HERSHEY PA
17033-2360
US

IV. Provider business mailing address

500 UNIVERSITY DR MC CA410
HERSHEY PA
17033-2360
US

V. Phone/Fax

Practice location:
  • Phone: 717-531-6820
  • Fax: 717-531-4702
Mailing address:
  • Phone: 717-531-5208
  • Fax: 717-531-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA61474
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067758
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: