Provider Demographics
NPI:1477936342
Name:MACREADY, JUSTINE (MS)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:MACREADY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 77TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-2904
Mailing Address - Country:US
Mailing Address - Phone:917-494-7695
Mailing Address - Fax:
Practice Address - Street 1:134 77TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-2904
Practice Address - Country:US
Practice Address - Phone:917-494-7695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019674-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker