Provider Demographics
NPI:1104382092
Name:DECESARE, MEREDITH EMILY (NP-C)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:EMILY
Last Name:DECESARE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1216
Mailing Address - Country:US
Mailing Address - Phone:229-251-3867
Mailing Address - Fax:
Practice Address - Street 1:2263 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-7316
Practice Address - Country:US
Practice Address - Phone:229-433-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN242990363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty