Healthcare Provider Details

I. General information

NPI: 1285332916
Provider Name (Legal Business Name): MARIE-LOURDES DERISSE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2023
Last Update Date: 02/22/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 BOSTON POST RD # 175
ORANGE CT
06477-3341
US

IV. Provider business mailing address

554 BOSTON POST RD 175
ORANGE CT
06477
US

V. Phone/Fax

Practice location:
  • Phone: 203-815-9279
  • Fax:
Mailing address:
  • Phone: 203-815-9279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number479264
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: