Provider Demographics
NPI:1558049791
Name:PERALTA, ROSANNA DEJESUS
Entity Type:Individual
Prefix:
First Name:ROSANNA
Middle Name:DEJESUS
Last Name:PERALTA
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 1:10 WESTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1014
Mailing Address - Country:US
Mailing Address - Phone:631-897-4333
Mailing Address - Fax:
Practice Address - Street 1:10 WESTBROOK RD
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1014
Practice Address - Country:US
Practice Address - Phone:631-897-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY635616-1163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine