Provider Demographics
NPI:1679888929
Name:DESARME, MIREILLE MARIE
Entity Type:Individual
Prefix:
First Name:MIREILLE
Middle Name:MARIE
Last Name:DESARME
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 1:19024 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2012
Mailing Address - Country:US
Mailing Address - Phone:718-468-1364
Mailing Address - Fax:
Practice Address - Street 1:19024 111TH AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2012
Practice Address - Country:US
Practice Address - Phone:718-468-1364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY494388-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse