Basic Information
| Provider Information | |||||||||
| NPI: | 1538199807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESERMIA | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAURENT | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5860 RANCH LAKE BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342023719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412292122 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5860 RANCH LAKE BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342023719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412292122 | ||||||||
| FaxNumber: | 9417573732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231H00000X | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.