Provider Demographics
NPI:1225615685
Name:DACISSE, KETHLINE JEAN
Entity Type:Individual
Prefix:
First Name:KETHLINE
Middle Name:JEAN
Last Name:DACISSE
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 WHALEY ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-4920
Mailing Address - Country:US
Mailing Address - Phone:516-643-7752
Mailing Address - Fax:
Practice Address - Street 1:800 FRONT ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4600
Practice Address - Country:US
Practice Address - Phone:516-705-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY481694163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology