Provider Demographics
NPI:1588412084
Name:DESOUZA, DIEDRE
Entity type:Individual
Prefix:MISS
First Name:DIEDRE
Middle Name:
Last Name:DESOUZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-1921
Mailing Address - Country:US
Mailing Address - Phone:860-679-2147
Mailing Address - Fax:860-679-4624
Practice Address - Street 1:263 FARMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-1127
Practice Address - Country:US
Practice Address - Phone:860-679-3600
Practice Address - Fax:860-679-1275
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program