MEDICARE: MS. KELLY DESIR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	PSI38194	FL

General Provider Information

NPI Number	:	1104413905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY DESIR

Provider Business Mailing Address
First Line	:	10234 ISLE WYND CT
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437-5501
Country	:	US
Telephone Number	:	561-389-1155
Fax Number	:

Provider Business Practice Location Address
First Line	:	4501 NW 31ST AVE
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33309-3403
Country	:	US
Telephone Number	:	754-223-7701
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2020
Last Update Date	:	12/28/2020

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