Healthcare Provider Details

I. General information

NPI: 1700557584
Provider Name (Legal Business Name): COURTNEYBELLE MUNRO DESROBERTS BSN, RN, CPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 09/22/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 PLUM ST APT 403
SYRACUSE NY
13204-1525
US

IV. Provider business mailing address

525 PLUM ST APT 403
SYRACUSE NY
13204-1525
US

V. Phone/Fax

Practice location:
  • Phone: 315-200-5485
  • Fax:
Mailing address:
  • Phone: 315-200-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number718004
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number718004-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: