Healthcare Provider Details

I. General information

NPI: 1902052244
Provider Name (Legal Business Name): DEBRA OBOURKE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 HYLAN BLVD
STATEN ISLAND NY
10305-1906
US

IV. Provider business mailing address

114 SENECA ST
STATEN ISLAND NY
10310-2334
US

V. Phone/Fax

Practice location:
  • Phone: 718-979-6900
  • Fax:
Mailing address:
  • Phone: 718-619-5074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number208075
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: