Provider Demographics
NPI:1215995329
Name:DESOMMA, MISTY MICHELLE (ARNP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:MICHELLE
Last Name:DESOMMA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12778 VISTA PINE CIR
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-7973
Mailing Address - Country:US
Mailing Address - Phone:239-768-3252
Mailing Address - Fax:
Practice Address - Street 1:15641 NEW HAMPSHIRE CT
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4123
Practice Address - Country:US
Practice Address - Phone:239-275-4300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9179099363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health