Provider Demographics
NPI:1811395262
Name:MCINTOSH, JOYLENE GLORIA
Entity Type:Individual
Prefix:
First Name:JOYLENE
Middle Name:GLORIA
Last Name:MCINTOSH
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 1:9127 AVENUE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5227
Mailing Address - Country:US
Mailing Address - Phone:347-623-8084
Mailing Address - Fax:
Practice Address - Street 1:5510 AVENUE I
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-1706
Practice Address - Country:US
Practice Address - Phone:347-702-7294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY896325141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist