Provider Demographics
NPI:1154180289
Name:DEFOREST, JOANNA LYNNE (RN)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LYNNE
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3303
Mailing Address - Country:US
Mailing Address - Phone:929-282-8060
Mailing Address - Fax:
Practice Address - Street 1:102 RIVERS EDGE RD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-1163
Practice Address - Country:US
Practice Address - Phone:929-282-8060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY887356163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse