Healthcare Provider Details

I. General information

NPI: 1164297214
Provider Name (Legal Business Name): DESIREE S ADDY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARAI ADDY

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 SOLOMONS RD
FORT GREGG ADAMS VA
23801-1482
US

IV. Provider business mailing address

131 SOLOMONS RD
FORT GREGG ADAMS VA
23801-1482
US

V. Phone/Fax

Practice location:
  • Phone: 413-347-2002
  • Fax:
Mailing address:
  • Phone: 413-347-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0002103978
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002103978
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number0002103978
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: