Provider Demographics
NPI:1942787320
Name:DESROSIERS, KETSIA (RN)
Entity Type:Individual
Prefix:
First Name:KETSIA
Middle Name:
Last Name:DESROSIERS
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 1:219 BROOK ST
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-3511
Mailing Address - Country:US
Mailing Address - Phone:516-384-9224
Mailing Address - Fax:
Practice Address - Street 1:1610 OLD COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590
Practice Address - Country:US
Practice Address - Phone:516-228-4900
Practice Address - Fax:631-737-1441
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2019-05-01
Deactivation Date:2019-03-06
Deactivation Code:
Reactivation Date:2019-03-13
Provider Licenses
StateLicense IDTaxonomies
NY343477363LF0000X
NY632149163WG0000X
NY00632149163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily