Basic Information
| Provider Information | |||||||||
| NPI: | 1023013430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELERUYELLE | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | LEA | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 449 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457500449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 ANDERSON LN | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457865312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409842332 | ||||||||
| FaxNumber: | 7409844435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 01/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP08290 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000370964 | 01 | OH | ANTHEM | OTHER | 000000699818 | 01 | OH | ANTHEM | OTHER | 2588543 | 05 | OH | MEDICAID | P00231317 | 01 | OH | RRMCR | OTHER | 3810002943 | 05 | WV | MEDICAID |