Provider Demographics
NPI:1689754160
Name:DESILETS, THERESA JEANNE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:JEANNE
Last Name:DESILETS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:JEANNE
Other - Last Name:DEROCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 ALGONQUIN DR
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-1810
Mailing Address - Country:US
Mailing Address - Phone:603-355-1548
Mailing Address - Fax:
Practice Address - Street 1:590 COURT ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1719
Practice Address - Country:US
Practice Address - Phone:603-354-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0462352305363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTONP2165Medicaid
NHS96370Medicare UPIN