Provider Demographics
NPI:1942915111
Name:BUSH, DESIRAE D'SHAWN
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:D'SHAWN
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3576 ARLINGTON AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3907
Mailing Address - Country:US
Mailing Address - Phone:951-788-5905
Mailing Address - Fax:
Practice Address - Street 1:3576 ARLINGTON AVE STE 106
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3907
Practice Address - Country:US
Practice Address - Phone:951-788-5905
Practice Address - Fax:951-788-5903
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker