Provider Demographics
NPI:1306249735
Name:DESIMONE, JANINE (NPP)
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:
Last Name:DESIMONE
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BRASSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-3411
Mailing Address - Country:US
Mailing Address - Phone:631-921-1949
Mailing Address - Fax:
Practice Address - Street 1:47 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2881
Practice Address - Country:US
Practice Address - Phone:631-780-4103
Practice Address - Fax:631-250-9215
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY40 401937363LP0808X
NY475699-1390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program