Healthcare Provider Details

I. General information

NPI: 1124210117
Provider Name (Legal Business Name): MARY JO D'AGOSTINO N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GOOCH DRIVE COLLEGE OF WILLIAM AND MARY
WILLIAMSBURG VA
23185-8795
US

IV. Provider business mailing address

1 GOOCH DRIVE STUDENT HEALTH CENTER
WILLIAMSBURG VA
23185-8795
US

V. Phone/Fax

Practice location:
  • Phone: 757-221-4386
  • Fax: 757-221-1245
Mailing address:
  • Phone: 757-221-4386
  • Fax: 757-221-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024127880
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: