Healthcare Provider Details

I. General information

NPI: 1780910349
Provider Name (Legal Business Name): MARY GRACE OBRIEN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2009
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3651 HILL BLVD
JEFFERSON VALLEY NY
10535-1501
US

IV. Provider business mailing address

3651 HILL BLVD
JEFFERSON VALLEY NY
10535-1501
US

V. Phone/Fax

Practice location:
  • Phone: 914-384-2075
  • Fax: 914-243-5895
Mailing address:
  • Phone: 914-384-2075
  • Fax: 914-243-5895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF400751
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: