Healthcare Provider Details

I. General information

NPI: 1831831163
Provider Name (Legal Business Name): EMILY ANNE DESMEULES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 11/05/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 MAKI LN
MCCALL ID
83638-5073
US

IV. Provider business mailing address

348 MAKI LN
MCCALL ID
83638-5073
US

V. Phone/Fax

Practice location:
  • Phone: 802-291-3718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2909
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: