Healthcare Provider Details

I. General information

NPI: 1578752051
Provider Name (Legal Business Name): GERMAINE A DESRUISSEAUX NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 E 53RD ST
CHICAGO IL
60615-4008
US

IV. Provider business mailing address

161 WASHINGTON ST FL 14 EIGHT TOWER BRIDGE, SUITE 1400
CONSHOHOCKEN PA
19428-2083
US

V. Phone/Fax

Practice location:
  • Phone: 773-752-1425
  • Fax:
Mailing address:
  • Phone: 484-351-3206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209006672
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: