Provider Demographics
NPI:1407674369
Name:DESESA, KELLY DOLORES (RN, CLT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DOLORES
Last Name:DESESA
Suffix:
Gender:F
Credentials:RN, CLT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CONNOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-0001
Mailing Address - Country:US
Mailing Address - Phone:631-988-4717
Mailing Address - Fax:
Practice Address - Street 1:34 BAY ST
Practice Address - Street 2:
Practice Address - City:SAG HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11963-3104
Practice Address - Country:US
Practice Address - Phone:631-988-4717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY557727163W00000X, 163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No163W00000XNursing Service ProvidersRegistered Nurse