Healthcare Provider Details

I. General information

NPI: 1497058275
Provider Name (Legal Business Name): MARY TERESA DESANE APN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 AIRPORT RD
LAKEWOOD NJ
08701-5968
US

IV. Provider business mailing address

4 UPTON PL
OCEAN NJ
07712-3708
US

V. Phone/Fax

Practice location:
  • Phone: 732-276-1510
  • Fax: 732-363-5537
Mailing address:
  • Phone: 732-922-2078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number26NJ00299700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: