Provider Demographics
NPI:1467217703
Name:DEBRUYN, JOHANNA LISETTE (MSN, RN, PHN)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:LISETTE
Last Name:DEBRUYN
Suffix:
Gender:F
Credentials:MSN, RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 AMBER SKY ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-3729
Mailing Address - Country:US
Mailing Address - Phone:909-844-6563
Mailing Address - Fax:
Practice Address - Street 1:150 DISTRICT CENTER DR
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-3626
Practice Address - Country:US
Practice Address - Phone:760-835-9836
Practice Address - Fax:760-325-8730
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA802986163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool