Provider Demographics
NPI:1497104178
Name:DESROSIERS, FARAH (NP)
Entity Type:Individual
Prefix:
First Name:FARAH
Middle Name:
Last Name:DESROSIERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 TILESTON ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-6033
Mailing Address - Country:US
Mailing Address - Phone:617-953-0736
Mailing Address - Fax:
Practice Address - Street 1:1093 N MAIN ST STE 1B
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-2100
Practice Address - Country:US
Practice Address - Phone:781-963-7775
Practice Address - Fax:781-963-7776
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2293231363LA2200X, 363LP0808X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health