Healthcare Provider Details

I. General information

NPI: 1760058986
Provider Name (Legal Business Name): MARY GRACE OBRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 N MAIN ST
HONEOYE FALLS NY
14472-1041
US

IV. Provider business mailing address

59 N MAIN ST
HONEOYE FALLS NY
14472-1041
US

V. Phone/Fax

Practice location:
  • Phone: 585-236-3297
  • Fax:
Mailing address:
  • Phone: 585-236-3297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number787561
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: