Provider Demographics
NPI:1396477063
Name:KNISLEY-DESMOND, CARL MARTIN (HOME HEALTH NURSE)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:MARTIN
Last Name:KNISLEY-DESMOND
Suffix:
Gender:M
Credentials:HOME HEALTH NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34605-1483
Mailing Address - Country:US
Mailing Address - Phone:352-444-0222
Mailing Address - Fax:
Practice Address - Street 1:715 OAKDALE AVE APT 24
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-1913
Practice Address - Country:US
Practice Address - Phone:352-444-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710569752374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710569752OtherHOME HEALTH PROVIDER