Healthcare Provider Details

I. General information

NPI: 1609141613
Provider Name (Legal Business Name): ROBERTA J OHANLON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 REID AVE
STATEN ISLAND NY
10305-3617
US

IV. Provider business mailing address

41 REID AVE
STATEN ISLAND NY
10305-3617
US

V. Phone/Fax

Practice location:
  • Phone: 718-987-2031
  • Fax:
Mailing address:
  • Phone: 718-987-2031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number325713
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: