Healthcare Provider Details

I. General information

NPI: 1265628846
Provider Name (Legal Business Name): MICHELLE M DESJARDINS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 HOLT AVE
MANCHESTER NH
03109
US

IV. Provider business mailing address

1070 HOLT AVE
MANCHESTER NH
03109-5603
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-4111
  • Fax:
Mailing address:
  • Phone: 603-622-3781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number058508-23
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number058508-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: