Provider Demographics
NPI:1669541322
Name:DEROSA, ADRIENNE (NP)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:DEROSA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 283
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-0283
Mailing Address - Country:US
Mailing Address - Phone:718-283-8773
Mailing Address - Fax:718-283-8796
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-8773
Practice Address - Fax:718-283-8796
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315105163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02710227Medicaid
NY1640G1Medicare ID - Type Unspecified
NY02710227Medicaid