Basic Information
| Provider Information | |||||||||
| NPI: | 1942411418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSSETTE | ||||||||
| FirstName: | DELORANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | DELORANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1743 SYCAMORE AVE | ||||||||
| Address2: | MOHAVE MENTAL HEALTH CLINIC INC | ||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287578111 | ||||||||
| FaxNumber: | 9287573256 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 MARINA BLVD | ||||||||
| Address2: | MOHAVE MENTAL HEALTH CLINIC INC | ||||||||
| City: | BULLHEAD CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287585905 | ||||||||
| FaxNumber: | 9287588790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 10/31/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3624 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.