Provider Demographics
NPI:1013561182
Name:BALLESTEROS, DESIREE (NP)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 130TH ST SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-6401
Mailing Address - Country:US
Mailing Address - Phone:425-224-8200
Mailing Address - Fax:
Practice Address - Street 1:125 130TH ST SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6401
Practice Address - Country:US
Practice Address - Phone:425-224-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-28
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22945363LF0000X
WAAP61254008363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily