Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 6532 | AZ |
Y | 2251X0800X | Physical Therapist - Orthopedic | 6532 | AZ |
NPI | 1083112106 |
---|---|
Provider Name | Mrs. Marissa Lynn Desjardins |
First Address | Peoria, AZ 85381 |
Second Address | Peoria, AZ 85381 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2018 |
Last Update Date | 30/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
388526 | (05) | AZ |