Provider Demographics
NPI:1073060190
Name:DESIR, EGENIE
Entity Type:Individual
Prefix:
First Name:EGENIE
Middle Name:
Last Name:DESIR
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 1:102 EDITH ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-1749
Mailing Address - Country:US
Mailing Address - Phone:781-691-7130
Mailing Address - Fax:781-691-9398
Practice Address - Street 1:102 EDITH ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149
Practice Address - Country:US
Practice Address - Phone:781-691-7130
Practice Address - Fax:781-691-7130
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2308132163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse