Healthcare Provider Details

I. General information

NPI: 1467044644
Provider Name (Legal Business Name): MARY ELIZABETH O'DONOGHUE B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 KEITH ST
SAINT AUGUSTINE FL
32084-4944
US

IV. Provider business mailing address

96 KEITH ST
SAINT AUGUSTINE FL
32084-4944
US

V. Phone/Fax

Practice location:
  • Phone: 904-321-9616
  • Fax:
Mailing address:
  • Phone: 904-321-9616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: