Healthcare Provider Details

I. General information

NPI: 1154138352
Provider Name (Legal Business Name): DEARIE PREVENTATIVE MEDICINE PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 02/25/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 BROADWAY STE N
ALBANY NY
12207-2922
US

IV. Provider business mailing address

PO BOX 7241
TACOMA WA
98417-0241
US

V. Phone/Fax

Practice location:
  • Phone: 206-486-2053
  • Fax:
Mailing address:
  • Phone: 206-486-2053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER WHALEN
Title or Position: DIRECTOR
Credential:
Phone: 217-737-3508