Healthcare Provider Details

I. General information

NPI: 1376818880
Provider Name (Legal Business Name): MARYLOU O'ROURKE R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11436 202ND ST PS811Q@PS822
SAINT ALBANS NY
11412-2813
US

IV. Provider business mailing address

45 MIDWOOD RD
ROCKVILLE CENTRE NY
11570-2019
US

V. Phone/Fax

Practice location:
  • Phone: 718-217-8001
  • Fax: 718-464-6690
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number416754-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: