Healthcare Provider Details

I. General information

NPI: 1760311187
Provider Name (Legal Business Name): DEIRDRE SHAVON JOLIVETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 AMSTERDAM AVE
NEW YORK NY
10033-7320
US

IV. Provider business mailing address

7646 BRENTWOOD RD
PHILADELPHIA PA
19151-2021
US

V. Phone/Fax

Practice location:
  • Phone: 212-543-2782
  • Fax:
Mailing address:
  • Phone: 917-660-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number297038-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: