Provider Demographics
NPI:1669250098
Name:BOLLERUP, DESIREE (AGPCNP)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:BOLLERUP
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:
Other - Last Name:BOLLERUP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AGPCNP
Mailing Address - Street 1:284 PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:284 PULASKI RD
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1602
Practice Address - Country:US
Practice Address - Phone:631-425-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311371-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health