Provider Demographics
NPI:1336114156
Name:DESALLE, SHERRY L (FNP)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:L
Last Name:DESALLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SOUTH SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:IL
Mailing Address - Zip Code:61338
Mailing Address - Country:US
Mailing Address - Phone:815-445-2273
Mailing Address - Fax:815-445-2213
Practice Address - Street 1:320 SOUTH SECOND STREET
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:IL
Practice Address - Zip Code:61338
Practice Address - Country:US
Practice Address - Phone:815-445-2273
Practice Address - Fax:815-445-2213
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK24937Medicare ID - Type UnspecifiedMEDICARE