Provider Demographics
NPI:1033791108
Name:WHITE, DESZIRAE MONIQUE
Entity Type:Individual
Prefix:
First Name:DESZIRAE
Middle Name:MONIQUE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11459 MAYFIELD RD STE 117
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2363
Mailing Address - Country:US
Mailing Address - Phone:216-385-3407
Mailing Address - Fax:
Practice Address - Street 1:14602 LAKE SHORE BLVD APT 2
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-1251
Practice Address - Country:US
Practice Address - Phone:216-385-3407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide