Provider Demographics
NPI:1760669659
Name:DESRONVIL, KATHIA (NP)
Entity Type:Individual
Prefix:
First Name:KATHIA
Middle Name:
Last Name:DESRONVIL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6409 TRUXTON LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8099
Mailing Address - Country:US
Mailing Address - Phone:781-363-6938
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4870
Practice Address - Country:US
Practice Address - Phone:631-654-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC5005854363LA2100X
NC5004912363LA2100X
NC242218363LF0000X
MA268962363LF0000X
NY432891363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4135Medicaid
NC1760669659Medicaid
SCNP4135Medicaid
MA000484701Medicare PIN