Provider Demographics
NPI:1780069831
Name:DESIERTO, KELLY MULLEN (LAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MULLEN
Last Name:DESIERTO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:KAY
Other - Last Name:MULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5330 W DEVON AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4148
Mailing Address - Country:US
Mailing Address - Phone:773-682-7124
Mailing Address - Fax:
Practice Address - Street 1:5330 W DEVON AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4148
Practice Address - Country:US
Practice Address - Phone:773-682-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001110171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist