Provider Demographics
NPI:1679851190
Name:DESANTIS, ELIZABETH ANNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:180 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2012
Mailing Address - Country:US
Mailing Address - Phone:631-893-0150
Mailing Address - Fax:631-893-0146
Practice Address - Street 1:180 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-2012
Practice Address - Country:US
Practice Address - Phone:631-893-0150
Practice Address - Fax:631-893-0146
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330476-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily