Provider Demographics
NPI:1265929533
Name:LAVERY, DESIREE LYNN (NP-C)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:LYNN
Last Name:LAVERY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06787-1740
Mailing Address - Country:US
Mailing Address - Phone:860-384-0300
Mailing Address - Fax:
Practice Address - Street 1:205 S MAIN ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:CT
Practice Address - Zip Code:06787-1740
Practice Address - Country:US
Practice Address - Phone:860-283-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-22
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.007545363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner