Healthcare Provider Details

I. General information

NPI: 1114940780
Provider Name (Legal Business Name): ELIZABETH ANNE DESANTIS WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 OAK ST
CONWAY SC
29526-4560
US

IV. Provider business mailing address

1973 MEADOWOOD LN
LONGS SC
29568-6527
US

V. Phone/Fax

Practice location:
  • Phone: 843-365-3126
  • Fax:
Mailing address:
  • Phone: 843-399-0339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number2374
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: