Provider Demographics
NPI:1063883270
Name:DEROSSI-DACOSTA, JENNIFER (RN,CDE,CDOE)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEROSSI-DACOSTA
Suffix:
Gender:F
Credentials:RN,CDE,CDOE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:
Practice Address - Street 1:111 BREWSTER STREET
Practice Address - Street 2:CNEMG PRIMARY CARE AND SPECIALTY SERVICES
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4474
Practice Address - Country:US
Practice Address - Phone:401-729-2238
Practice Address - Fax:401-729-2923
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN51935163WD0400X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No174H00000XOther Service ProvidersHealth Educator