Healthcare Provider Details

I. General information

NPI: 1629597943
Provider Name (Legal Business Name): DESIRAE ARLETTE FAELE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142-02 20TH AVE
ROSEDALE NY
11351
US

IV. Provider business mailing address

14202 20TH AVE
FLUSHING NY
11351-3000
US

V. Phone/Fax

Practice location:
  • Phone: 917-563-3350
  • Fax:
Mailing address:
  • Phone: 917-563-3350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number734345
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: