Provider Demographics
NPI:1760070627
Name:PEARSON, DAIDRA
Entity Type:Individual
Prefix:
First Name:DAIDRA
Middle Name:
Last Name:PEARSON
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 1:6424 18TH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-3729
Mailing Address - Country:US
Mailing Address - Phone:212-687-7464
Mailing Address - Fax:
Practice Address - Street 1:6424 18TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3729
Practice Address - Country:US
Practice Address - Phone:212-687-7464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339917164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse