Provider Demographics
NPI:1790051910
Name:OUTLAW, DESIREE (NP)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 E PEMBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-2445
Mailing Address - Country:US
Mailing Address - Phone:757-379-1660
Mailing Address - Fax:
Practice Address - Street 1:1328 E PEMBROKE AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-2445
Practice Address - Country:US
Practice Address - Phone:757-379-1660
Practice Address - Fax:855-679-9729
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1292471363LF0000X
NY337212363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily