Provider Demographics
NPI:1487230777
Name:DESOTELL, LISA LYNN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:DESOTELL
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 1:1226 WAKEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750-9013
Mailing Address - Country:US
Mailing Address - Phone:989-414-9363
Mailing Address - Fax:
Practice Address - Street 1:1226 WAKEFIELD RD
Practice Address - Street 2:
Practice Address - City:OSCODA
Practice Address - State:MI
Practice Address - Zip Code:48750-9013
Practice Address - Country:US
Practice Address - Phone:989-414-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant