Provider Demographics
NPI:1669887766
Name:DESART, JENNY LEE (CRNA)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:LEE
Last Name:DESART
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:LYNN
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 603484
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3484
Mailing Address - Country:US
Mailing Address - Phone:803-765-1838
Mailing Address - Fax:803-765-1732
Practice Address - Street 1:2095 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5733
Practice Address - Country:US
Practice Address - Phone:843-402-1436
Practice Address - Fax:843-402-1833
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9297294367500000X
SC23729367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012764400Medicaid
FLHW592ZMedicare PIN