MEDICARE: CARINE DESROULEAUX RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	635279-1	NY

General Provider Information

NPI Number	:	1669983953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARINE DESROULEAUX RN

Provider Business Mailing Address
First Line	:	11836 NASHVILLE BLVD
Second Line	:
City	:	CAMBRIA HEIGHTS
State	:	NY
Zip	:	11411-1920
Country	:	US
Telephone Number	:	718-776-2422
Fax Number	:

Provider Business Practice Location Address
First Line	:	11836 NASHVILLE BLVD
Second Line	:
City	:	CAMBRIA HEIGHTS
State	:	NY
Zip	:	11411-1920
Country	:	US
Telephone Number	:	917-335-3458
Fax Number	:	917-335-3458

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2017
Last Update Date	:	10/13/2017

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