Provider Demographics
NPI:1578752051
Name:DESRUISSEAUX, GERMAINE A (NP)
Entity Type:Individual
Prefix:MRS
First Name:GERMAINE
Middle Name:A
Last Name:DESRUISSEAUX
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 1:161 WASHINGTON ST FL 14
Mailing Address - Street 2:EIGHT TOWER BRIDGE, SUITE 1400
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2083
Mailing Address - Country:US
Mailing Address - Phone:484-351-3206
Mailing Address - Fax:
Practice Address - Street 1:1228 E 53RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4008
Practice Address - Country:US
Practice Address - Phone:773-752-1425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR00825Medicare UPIN
ILR00824Medicare UPIN