Provider Demographics
NPI:1104382084
Name:DESROSIERS, MYRLENE (FNP)
Entity Type:Individual
Prefix:
First Name:MYRLENE
Middle Name:
Last Name:DESROSIERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 WOODSTEAD CT STE 208
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1480
Mailing Address - Country:US
Mailing Address - Phone:877-749-7428
Mailing Address - Fax:512-628-3314
Practice Address - Street 1:2020 MCGEE RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2992
Practice Address - Country:US
Practice Address - Phone:877-749-7428
Practice Address - Fax:512-628-3314
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN126935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily