Healthcare Provider Details

I. General information

NPI: 1285025965
Provider Name (Legal Business Name): SHANIKA DESMOULIN RN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 BROOKLAWN PL
BRIDGEPORT CT
06604-2117
US

IV. Provider business mailing address

31 BROOKLAWN PL
BRIDGEPORT CT
06604-2117
US

V. Phone/Fax

Practice location:
  • Phone: 917-651-9240
  • Fax:
Mailing address:
  • Phone: 917-651-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3819392
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number738515
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number320771
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: