Provider Demographics
NPI:1720252919
Name:DESROCHER, RENAY LEE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:RENAY
Middle Name:LEE
Last Name:DESROCHER
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 STRATTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST CHAZY
Mailing Address - State:NY
Mailing Address - Zip Code:12992-3630
Mailing Address - Country:US
Mailing Address - Phone:518-493-4134
Mailing Address - Fax:
Practice Address - Street 1:412 STRATTON HILL RD
Practice Address - Street 2:
Practice Address - City:WEST CHAZY
Practice Address - State:NY
Practice Address - Zip Code:12992-3630
Practice Address - Country:US
Practice Address - Phone:518-493-4134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22379141163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02923393Medicaid