Healthcare Provider Details

I. General information

NPI: 1164053583
Provider Name (Legal Business Name): JOURNYE CORYNNE MACDONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 DANBY RD
ITHACA NY
14850-7000
US

IV. Provider business mailing address

735 CHURCHLAND RD
SAUGERTIES NY
12477-4626
US

V. Phone/Fax

Practice location:
  • Phone: 845-243-4534
  • Fax:
Mailing address:
  • Phone: 845-243-4534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: