Provider Demographics
NPI:1083205348
Name:DIEUJUSTE, LOURNA VANESSA
Entity Type:Individual
Prefix:
First Name:LOURNA
Middle Name:VANESSA
Last Name:DIEUJUSTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FERRIS AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-7701
Mailing Address - Country:US
Mailing Address - Phone:631-873-9826
Mailing Address - Fax:
Practice Address - Street 1:11 FERRIS AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-7701
Practice Address - Country:US
Practice Address - Phone:631-873-9826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336906164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty