Provider Demographics
NPI:1487306999
Name:DELAWDER, DESIREE G
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:G
Last Name:DELAWDER
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 1:4962 STATE ROUTE 138
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-7518
Mailing Address - Country:US
Mailing Address - Phone:937-288-2203
Mailing Address - Fax:
Practice Address - Street 1:4962 STATE ROUTE 138
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-7518
Practice Address - Country:US
Practice Address - Phone:937-288-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0473981Medicaid