Provider Demographics
NPI:1760533350
Name:CUNNINGHAM-DESHONG, HOMER (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:
Last Name:CUNNINGHAM-DESHONG
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MRS
Other - First Name:HOMER
Other - Middle Name:
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:1058 E 99TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4414
Mailing Address - Country:US
Mailing Address - Phone:718-242-8578
Mailing Address - Fax:718-241-8578
Practice Address - Street 1:234 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5504
Practice Address - Country:US
Practice Address - Phone:718-579-6011
Practice Address - Fax:718-570-4822
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303316363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health