Provider Demographics
NPI:1043674922
Name:ETIENNE, ROUSSEAU
Entity type:Individual
Prefix:
First Name:ROUSSEAU
Middle Name:
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 REMSEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5233
Mailing Address - Country:US
Mailing Address - Phone:917-335-7427
Mailing Address - Fax:718-287-4600
Practice Address - Street 1:1695 REMSEN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5233
Practice Address - Country:US
Practice Address - Phone:917-335-7427
Practice Address - Fax:718-287-4600
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325167164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse