Healthcare Provider Details

I. General information

NPI: 1902281884
Provider Name (Legal Business Name): MRS. FRANSISE DEREZIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 SW MOSELLE AVE
PORT ST LUCIE FL
34984-5028
US

IV. Provider business mailing address

256 SW MOSELLE AVE
PORT ST LUCIE FL
34984-5028
US

V. Phone/Fax

Practice location:
  • Phone: 718-838-4313
  • Fax: 772-237-2234
Mailing address:
  • Phone: 718-838-4313
  • Fax: 772-237-2234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberAL12659
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License NumberAL12659
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: