Healthcare Provider Details

I. General information

NPI: 1235864919
Provider Name (Legal Business Name): RUTH JENNIFER DESORMEAU FNP- BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 GRACE ST
BALDWIN NY
11510-3905
US

IV. Provider business mailing address

808 GRACE ST
BALDWIN NY
11510-3905
US

V. Phone/Fax

Practice location:
  • Phone: 646-761-4826
  • Fax:
Mailing address:
  • Phone: 646-761-4826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number349884
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: