Provider Demographics
NPI:1710561592
Name:DERISBRUN, EMMANUELA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:EMMANUELA
Middle Name:
Last Name:DERISBRUN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 FLAGSTONE CT
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-3634
Mailing Address - Country:US
Mailing Address - Phone:407-446-8757
Mailing Address - Fax:
Practice Address - Street 1:1068 FLAGSTONE CT
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-3634
Practice Address - Country:US
Practice Address - Phone:407-446-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF12200582363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner