Healthcare Provider Details

I. General information

NPI: 1841185014
Provider Name (Legal Business Name): GREGORY ROUSSEAU
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2025
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 BROOKSIDE AVE UNIT 2
MOUNT VERNON NY
10553-1304
US

IV. Provider business mailing address

194 BROOKSIDE AVE UNIT 2
MOUNT VERNON NY
10553-1304
US

V. Phone/Fax

Practice location:
  • Phone: 929-351-9548
  • Fax:
Mailing address:
  • Phone: 929-351-9548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number311471
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: