Healthcare Provider Details

I. General information

NPI: 1710596077
Provider Name (Legal Business Name): CECILE ELIZABETH DEFALCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD
RICHMOND VA
23225-4044
US

IV. Provider business mailing address

603 LARRYMORE CT
RICHMOND VA
23225-6015
US

V. Phone/Fax

Practice location:
  • Phone: 204-483-0000
  • Fax:
Mailing address:
  • Phone: 810-333-0399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001264810
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: