Provider Demographics
NPI:1184102493
Name:DEROSE, DONNA MARIE (RN)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:DEROSE
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 1:21 GREENE CT
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4355
Mailing Address - Country:US
Mailing Address - Phone:631-885-7840
Mailing Address - Fax:631-979-8578
Practice Address - Street 1:21 GREENE CT
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4355
Practice Address - Country:US
Practice Address - Phone:631-885-7840
Practice Address - Fax:631-979-8578
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404965163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse