Healthcare Provider Details

I. General information

NPI: 1518450238
Provider Name (Legal Business Name): DESIREE ANN YEBOAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4471
  • Fax: 401-444-7574
Mailing address:
  • Phone: 401-444-4471
  • Fax: 401-444-7574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLP04345
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: