Provider Demographics
NPI:1336340413
Name:ORTEGA, DESIREE
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:
Last Name:ORTEGA
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 1:3275 PINTAIL CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-2617
Mailing Address - Country:US
Mailing Address - Phone:907-357-8028
Mailing Address - Fax:907-357-8028
Practice Address - Street 1:3275 PINTAIL CIR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-2617
Practice Address - Country:US
Practice Address - Phone:907-357-8028
Practice Address - Fax:907-357-8028
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCM14941171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM14941Medicaid