Provider Demographics
NPI:1336484732
Name:O'DRISCOLL, JOAN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:O'DRISCOLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 GROVE AVE
Mailing Address - Street 2:BUILDING C
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 GROVE AVE
Practice Address - Street 2:BUILDING C
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-1730
Practice Address - Country:US
Practice Address - Phone:845-667-1039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00268300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist