Provider Demographics
NPI:1578835427
Name:DEFREITAS-GORDON, MONIQUE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:
Last Name:DEFREITAS-GORDON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:MONIQUE
Other - Middle Name:
Other - Last Name:DEFREITAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:804 E 138TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-1902
Mailing Address - Country:US
Mailing Address - Phone:718-665-7500
Mailing Address - Fax:718-665-4768
Practice Address - Street 1:804 E 138TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-1902
Practice Address - Country:US
Practice Address - Phone:718-665-7500
Practice Address - Fax:718-665-4768
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY529191-1163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)