Basic Information
| Provider Information | |||||||||
| NPI: | 1821176264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ALICE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58 LUSK ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077636293 | ||||||||
| FaxNumber: | 6077636717 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 FRONT ST | ||||||||
| Address2: | |||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138501559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6076581003 | ||||||||
| FaxNumber: | 6076581006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 02/16/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 526565 | NY | N | Nursing Service Providers | Registered Nurse | 363L00000X | F-334399 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 02892717 | 05 | NY | MEDICAID |