Provider Demographics
NPI:1194181370
Name:DESIONGCO, MA JANICE LALITHA A (NP)
Entity Type:Individual
Prefix:
First Name:MA JANICE LALITHA
Middle Name:A
Last Name:DESIONGCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MA. JANICE LALITHA
Other - Middle Name:SERIO
Other - Last Name:AMIHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:BANNER MD ANDERSON CANCER CENTER
Mailing Address - Street 2:2940 E. BANNER GATEWAY DRIVE SUITE 450
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:480-256-3682
Practice Address - Street 1:BANNER MD ANDERSON CANCER CENTER
Practice Address - Street 2:2946 E. BANNER GATEWAY DRIVE
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-3682
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8366363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ108012Medicaid