Provider Demographics
NPI:1285740324
Name:DEROSENA, MARYSE BEAUDOUIN (BS MHA LDN)
Entity type:Individual
Prefix:MRS
First Name:MARYSE
Middle Name:BEAUDOUIN
Last Name:DEROSENA
Suffix:
Gender:F
Credentials:BS MHA LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 ESSINGTON RD
Mailing Address - Street 2:SUITE # 80
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-1200
Mailing Address - Country:US
Mailing Address - Phone:815-236-6441
Mailing Address - Fax:630-293-2937
Practice Address - Street 1:2405 ESSINGTON RD
Practice Address - Street 2:SUITE # 80
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1200
Practice Address - Country:US
Practice Address - Phone:815-236-6441
Practice Address - Fax:630-293-2937
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered