Healthcare Provider Details

I. General information

NPI: 1417678939
Provider Name (Legal Business Name): CHRISTINE DELA CRUZ MLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2022
Last Update Date: 09/05/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 GRANBY ST STE 202
NORFOLK VA
23510-2009
US

IV. Provider business mailing address

1801 COLONIAL ARMS CIR APT A3
VIRGINIA BEACH VA
23454-3006
US

V. Phone/Fax

Practice location:
  • Phone: 757-774-7779
  • Fax:
Mailing address:
  • Phone: 757-319-9706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number25694701
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: