Provider Demographics
NPI:1235433160
Name:BOURJOLLY, DAPHNEY (DAPHNEY BOURJOLLY)
Entity Type:Individual
Prefix:
First Name:DAPHNEY
Middle Name:
Last Name:BOURJOLLY
Suffix:
Gender:F
Credentials:DAPHNEY BOURJOLLY
Other - Prefix:
Other - First Name:DAPHNEY
Other - Middle Name:
Other - Last Name:BOURJOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:125 HAWTHORNE AVE
Mailing Address - Street 2:346
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-1367
Mailing Address - Country:US
Mailing Address - Phone:631-327-6969
Mailing Address - Fax:631-623-6152
Practice Address - Street 1:125 HAWTHORNE AVE
Practice Address - Street 2:346
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-1367
Practice Address - Country:US
Practice Address - Phone:631-327-6969
Practice Address - Fax:631-623-6152
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304080164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse