Provider Demographics
NPI:1154780096
Name:DERISO, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:DERISO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 NATHAN HALE DR
Mailing Address - Street 2:APT 73A
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-7035
Mailing Address - Country:US
Mailing Address - Phone:631-926-2199
Mailing Address - Fax:
Practice Address - Street 1:28 NATHAN HALE DR
Practice Address - Street 2:APT 73A
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-7035
Practice Address - Country:US
Practice Address - Phone:631-926-2199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-21
Last Update Date:2016-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1084415174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist