MEDICARE: DUSTY SHANNON DELHAGEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1023509791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTY SHANNON DELHAGEN

Provider Business Mailing Address
First Line	:	44550 VILLAGE CT STE 103
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92260-3817
Country	:	US
Telephone Number	:	951-396-1395
Fax Number	:

Provider Business Practice Location Address
First Line	:	44550 VILLAGE CT STE 103
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92260-3817
Country	:	US
Telephone Number	:	714-469-3772
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2018
Last Update Date	:	09/26/2024

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