Provider Demographics
NPI:1093469793
Name:DESANDIS, KRISTEN KALA (AG-ACNP, BC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:KALA
Last Name:DESANDIS
Suffix:
Gender:F
Credentials:AG-ACNP, BC
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:KALA
Other - Last Name:BREEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 REVERE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3812
Mailing Address - Country:US
Mailing Address - Phone:540-664-4846
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:ATTN: CENTRAL CREDENTIALING OFFICE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA549912241844363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine