=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912253592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YUNIQUE A DESIRE-BRISARD FNP LNC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2012
-----------------------------------------------------
Last Update Date | 08/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1339 E 104TH STREET
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-373-2563
-----------------------------------------------------
Fax | 718-339-4470
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 380 AVENUE U STE# 1L
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11223-4046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-373-2563
-----------------------------------------------------
Fax | 718-339-4470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | YUNIQUE AMBER DESIRE-BRISARD
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 718-373-2563
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 333149
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------