MEDICARE: JOHANNE DESIRE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	309079	NY
2	163W00000X	Registered Nurse	786895	NY

General Provider Information

NPI Number	:	1356805279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHANNE DESIRE

Provider Business Mailing Address
First Line	:	9901 SEAVIEW AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-5519
Country	:	US
Telephone Number	:	347-353-5177
Fax Number	:

Provider Business Practice Location Address
First Line	:	9901 SEAVIEW AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-5519
Country	:	US
Telephone Number	:	347-353-5177
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2019
Last Update Date	:	06/08/2020

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Directions to “ JOHANNE DESIRE ” Practice Location

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