Provider Demographics
NPI:1568645406
Name:MONDESIR, ROSE YANICK
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:YANICK
Last Name:MONDESIR
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 1:9904 216TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1123
Mailing Address - Country:US
Mailing Address - Phone:718-465-2752
Mailing Address - Fax:
Practice Address - Street 1:1111 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-9064
Practice Address - Country:US
Practice Address - Phone:718-272-0346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051841183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01507648Medicaid