Provider Demographics
NPI:1558794909
Name:DESOUCY, RENEE DOREANE (NP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:DOREANE
Last Name:DESOUCY
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 1:1601 YGNACIO VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3122
Mailing Address - Country:US
Mailing Address - Phone:925-212-7052
Mailing Address - Fax:
Practice Address - Street 1:1601 YGNACIO VALLEY RD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3122
Practice Address - Country:US
Practice Address - Phone:925-212-7052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001577363L00000X
CACA 22482363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVAPRN001577OtherAPRN LICENSE
CACA 22482OtherCA APRN