MEDICARE: DESIREE LYNN LAVERY NP-C

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	363L00000X	Nurse Practitioner	12.007545	CT

General Provider Information

NPI Number	:	1265929533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESIREE LYNN LAVERY NP-C

Provider Business Mailing Address
First Line	:	205 S MAIN ST
Second Line	:
City	:	THOMASTON
State	:	CT
Zip	:	06787-1740
Country	:	US
Telephone Number	:	860-384-0300
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 S MAIN ST
Second Line	:
City	:	THOMASTON
State	:	CT
Zip	:	06787-1740
Country	:	US
Telephone Number	:	860-283-6255
Fax Number	:

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

Provider Enumeration Date	:	04/22/2018
Last Update Date	:	05/09/2019

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