Provider Demographics
NPI:1912453796
Name:KENENI, DERESE
Entity Type:Individual
Prefix:
First Name:DERESE
Middle Name:
Last Name:KENENI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 ODELL STREET
Mailing Address - Street 2:1G
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462
Mailing Address - Country:US
Mailing Address - Phone:646-236-4884
Mailing Address - Fax:
Practice Address - Street 1:1575 ODELL ST
Practice Address - Street 2:1G
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-7053
Practice Address - Country:US
Practice Address - Phone:646-236-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY715453163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse