=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780195446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOROTHY MAY DESIERTO AGDAMAG APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2017
-----------------------------------------------------
Last Update Date | 03/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4919 W CRAIG RD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89130-2730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 725-220-8706
-----------------------------------------------------
Fax | 833-749-0366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6101 BLUE LAGOON DR STE 200
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-500-2000
-----------------------------------------------------
Fax | 843-277-9070
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN002721
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------