Healthcare Provider Details

I. General information

NPI: 1871362707
Provider Name (Legal Business Name): BRIAN B O'DONOHUE R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 12/20/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 ASHLEY AVE
MIDDLETOWN NY
10940-1912
US

IV. Provider business mailing address

21 WATER STREET
WURTSBORO NY
12790-0465
US

V. Phone/Fax

Practice location:
  • Phone: 845-326-8059
  • Fax:
Mailing address:
  • Phone: 845-313-4503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number476883
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: