Provider Demographics
NPI:1861688566
Name:DEROSIER, CATHY JO (RN)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:JO
Last Name:DEROSIER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S LAKE AVE
Mailing Address - Street 2:SUITE 222
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2362
Mailing Address - Country:US
Mailing Address - Phone:218-279-8372
Mailing Address - Fax:
Practice Address - Street 1:525 S LAKE AVE
Practice Address - Street 2:SUITE 222
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2362
Practice Address - Country:US
Practice Address - Phone:218-279-8372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 118118-0163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse