Provider Demographics
NPI:1710148903
Name:ROUSSEAU-AMY, YOLETTE (RN)
Entity Type:Individual
Prefix:
First Name:YOLETTE
Middle Name:
Last Name:ROUSSEAU-AMY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1339
Mailing Address - Country:US
Mailing Address - Phone:631-846-4202
Mailing Address - Fax:
Practice Address - Street 1:71 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1339
Practice Address - Country:US
Practice Address - Phone:631-846-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY523854163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY523854Medicaid