Healthcare Provider Details

I. General information

NPI: 1811597578
Provider Name (Legal Business Name): DESIRAE LEANN CHITISHVILI CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DESIRAE LEANN FARIAS

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US ARMY MEDICAL ACTIVITY-BAVARIA UNIT 28038 ATTN: MCEU-BAV-CRE
APO AE
09112
US

IV. Provider business mailing address

US ARMY MEDICAL ACTIVITY-BAVARIA UNIT 28038, ATTN: MCEU
APO AE
09112
US

V. Phone/Fax

Practice location:
  • Phone: 719-464-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number00779888
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: