Provider Demographics
NPI:1912212341
Name:DESSOURCES, ISMAELLE
Entity Type:Individual
Prefix:
First Name:ISMAELLE
Middle Name:
Last Name:DESSOURCES
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 1:7419 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-3022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 PENN ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19602-1000
Practice Address - Country:US
Practice Address - Phone:610-372-7712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN285020164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse