Provider Demographics
NPI:1235864919
Name:DESORMEAU, RUTH JENNIFER (FNP- BC)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:JENNIFER
Last Name:DESORMEAU
Suffix:
Gender:F
Credentials:FNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 GRACE ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3905
Mailing Address - Country:US
Mailing Address - Phone:646-761-4826
Mailing Address - Fax:
Practice Address - Street 1:808 GRACE ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3905
Practice Address - Country:US
Practice Address - Phone:646-761-4826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349884363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily