Provider Demographics
NPI:1740883719
Name:DESIMONE, GIAVANNA (LAT, ATC)
Entity type:Individual
Prefix:
First Name:GIAVANNA
Middle Name:
Last Name:DESIMONE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 GOFFLE RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4033
Mailing Address - Country:US
Mailing Address - Phone:201-206-1516
Mailing Address - Fax:
Practice Address - Street 1:321 GOFFLE RD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4033
Practice Address - Country:US
Practice Address - Phone:201-206-1516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002649002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MT00264900OtherLICENSE