Provider Demographics
NPI:1962265132
Name:DESRUISSEAUX, JOHANE N/A (NP)
Entity type:Individual
Prefix:
First Name:JOHANE
Middle Name:N/A
Last Name:DESRUISSEAUX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E 33RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5337
Mailing Address - Country:US
Mailing Address - Phone:212-366-4459
Mailing Address - Fax:
Practice Address - Street 1:81 JUNIUS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-8004
Practice Address - Country:US
Practice Address - Phone:718-866-1055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF405123-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health