Provider Demographics
NPI:1689923054
Name:DEJESUS, RAQUEL (MSN, NP-C)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 INTERNATIONAL CT
Mailing Address - Street 2:APT 13
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103
Mailing Address - Country:US
Mailing Address - Phone:203-394-3745
Mailing Address - Fax:
Practice Address - Street 1:4421 INTERNATIONAL CT
Practice Address - Street 2:APT 13
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103
Practice Address - Country:US
Practice Address - Phone:203-394-3745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004072A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily