=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528608759
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDACE ELISABETH DEL VALLE LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2020
-----------------------------------------------------
Last Update Date | 12/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18511 HIGHLANDER MEDICS ST
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79906-5327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-742-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1448 GROVE PARK DR APT 1311
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31904-1598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-360-0821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2000040799
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT004253
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT9945
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------