Healthcare Provider Details

I. General information

NPI: 1154902468
Provider Name (Legal Business Name): SHAYNA LEE DESANDO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WAKE FOREST SCHOOL OF MEDICINE MEDICAL CENTER BOULEVARD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

167 GAILLARDIA WAY
CLAYTON NC
27527-6703
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4311
  • Fax: 336-716-7595
Mailing address:
  • Phone: 860-839-9223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2024-02791
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: