Provider Demographics
NPI:1497058275
Name:DESANE, MARY TERESA (APN-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:DESANE
Suffix:
Gender:F
Credentials:APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 UPTON PL
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-3708
Mailing Address - Country:US
Mailing Address - Phone:732-922-2078
Mailing Address - Fax:
Practice Address - Street 1:725 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5968
Practice Address - Country:US
Practice Address - Phone:732-276-1510
Practice Address - Fax:732-363-5537
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00299700163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult