Provider Demographics
NPI:1164213112
Name:DELVALLE, LAKISHA
Entity type:Individual
Prefix:
First Name:LAKISHA
Middle Name:
Last Name:DELVALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CLOVER AVE
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-3615
Mailing Address - Country:US
Mailing Address - Phone:609-209-6072
Mailing Address - Fax:
Practice Address - Street 1:1417 BRACE RD STE C
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-3524
Practice Address - Country:US
Practice Address - Phone:856-333-3783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJINTERN363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health