Provider Demographics
NPI:1174940662
Name:FRASER, DESIANNE NATANYA (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:DESIANNE
Middle Name:NATANYA
Last Name:FRASER
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 E 242ND ST APT 2C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-1233
Mailing Address - Country:US
Mailing Address - Phone:914-406-2817
Mailing Address - Fax:
Practice Address - Street 1:1822 STILLWELL AVE
Practice Address - Street 2:FRONT DESK
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-1233
Practice Address - Country:US
Practice Address - Phone:718-652-7939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY666082-1163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice