Provider Demographics
NPI:1972295442
Name:AUGUSTAVE, DERISE
Entity Type:Individual
Prefix:MRS
First Name:DERISE
Middle Name:
Last Name:AUGUSTAVE
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 1:155 S CLINTON ST BLDG B
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-3039
Mailing Address - Country:US
Mailing Address - Phone:914-268-5537
Mailing Address - Fax:
Practice Address - Street 1:155 S CLINTON ST BLDG B
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-3039
Practice Address - Country:US
Practice Address - Phone:914-268-5537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342151164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse