Provider Demographics
NPI:1871143578
Name:DESULME, GARRY (ARNP)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:
Last Name:DESULME
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 SW DONNA TER
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4358
Mailing Address - Country:US
Mailing Address - Phone:772-203-2661
Mailing Address - Fax:
Practice Address - Street 1:1700 S 23RD ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4803
Practice Address - Country:US
Practice Address - Phone:772-203-2661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004108363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology