Provider Demographics
NPI:1386934339
Name:FANA-PEREZ, ROSEANN DARLISSA (MD)
Entity type:Individual
Prefix:
First Name:ROSEANN
Middle Name:DARLISSA
Last Name:FANA-PEREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROSEANN
Other - Middle Name:DARLISSA
Other - Last Name:FANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6750 THORNTON PL APT 4P
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4173
Mailing Address - Country:US
Mailing Address - Phone:347-475-0117
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:347-475-0117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2014-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY602610672084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry