Provider Demographics
NPI:1821678368
Name:DESANDRE, ELIZABETH WARREN (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WARREN
Last Name:DESANDRE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:584 HOSPITAL DR NE UNIT D
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-0020
Practice Address - Country:US
Practice Address - Phone:910-721-4150
Practice Address - Fax:910-721-4159
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC272250163W00000X
NC5014307363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse