Provider Demographics
NPI:1316533276
Name:BOURSIQUOT, DEANNA LAVERNE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:LAVERNE
Last Name:BOURSIQUOT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:LAVERNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 WESTCHESTER AVE
Mailing Address - Street 2:STE N715
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-1369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-2901
Practice Address - Country:US
Practice Address - Phone:914-682-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346746363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily