Provider Demographics
NPI:1750830642
Name:HALLORAN, THERESA JOYCE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:JOYCE
Last Name:HALLORAN
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 1:381 COTTEKILL RD
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-5103
Mailing Address - Country:US
Mailing Address - Phone:845-594-1639
Mailing Address - Fax:
Practice Address - Street 1:381 COTTEKILL RD
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5103
Practice Address - Country:US
Practice Address - Phone:845-594-1639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339720-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily