Provider Demographics
NPI:1790937894
Name:PENN DURANDISSE, HERLANDE (FNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:HERLANDE
Middle Name:
Last Name:PENN DURANDISSE
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 E 103RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4502
Mailing Address - Country:US
Mailing Address - Phone:347-489-9954
Mailing Address - Fax:
Practice Address - Street 1:513 W 166TH ST FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-4207
Practice Address - Country:US
Practice Address - Phone:212-928-8300
Practice Address - Fax:212-928-8392
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334928363LF0000X
NYF404031363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3108849Medicaid