MEDICARE: DARDA DETERVILLE

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	163WS0200X	School Registered Nurse	4298041	NY

General Provider Information

NPI Number	:	1417269416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARDA DETERVILLE

Provider Business Mailing Address
First Line	:	6744 190 LANE
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11365-0000
Country	:	US
Telephone Number	:	718-454-2818
Fax Number	:

Provider Business Practice Location Address
First Line	:	6744 190 LANE
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11365-0000
Country	:	US
Telephone Number	:	718-454-2818
Fax Number	:

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

Provider Enumeration Date	:	07/07/2010
Last Update Date	:	07/07/2010

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Directions to “ DARDA DETERVILLE ” Practice Location

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