Healthcare Provider Details

I. General information

NPI: 1407397920
Provider Name (Legal Business Name): KATHLEEN ANN O'SHEA APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E CHURCH ST
BLACKWOOD NJ
08012-3910
US

IV. Provider business mailing address

400 E CHURCH ST
BLACKWOOD NJ
08012-3910
US

V. Phone/Fax

Practice location:
  • Phone: 856-227-6575
  • Fax: 856-374-9495
Mailing address:
  • Phone: 856-227-6575
  • Fax: 856-374-9495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ00706400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: