Provider Demographics
NPI:1982474623
Name:SMITH, DESIREE ANN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15954 RIVERSEDGE DR
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:
Practice Address - Street 1:15954 RIVERSEDGE DR
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843
Practice Address - Country:US
Practice Address - Phone:715-634-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16057-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health