MEDICARE: KELLY DOLORES DESESA RN, CLT

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	163W00000X	Registered Nurse	557727	NY
2	163WM1400X	Nurse Massage Therapist (NMT)	557727	NY

General Provider Information

NPI Number	:	1407674369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY DOLORES DESESA RN, CLT

Provider Business Mailing Address
First Line	:	PO BOX 52
Second Line	:
City	:	SAG HARBOR
State	:	NY
Zip	:	11963-0001
Country	:	US
Telephone Number	:	631-988-4717
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 BAY ST
Second Line	:
City	:	SAG HARBOR
State	:	NY
Zip	:	11963-3104
Country	:	US
Telephone Number	:	631-988-4717
Fax Number	:

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

Provider Enumeration Date	:	09/30/2024
Last Update Date	:	09/30/2024

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