Provider Demographics
NPI:1467936088
Name:CARTER, DESIREE MICHELLETTE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:MICHELLETTE
Last Name:CARTER
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 1:779 MONUMENT AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-5406
Mailing Address - Country:US
Mailing Address - Phone:757-775-2455
Mailing Address - Fax:
Practice Address - Street 1:779 MONUMENT AVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-5406
Practice Address - Country:US
Practice Address - Phone:757-775-2455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002090993164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse