Provider Demographics
NPI:1821176264
Name:O'BRIEN, MARY ALICE (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 LUSK ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2541
Mailing Address - Country:US
Mailing Address - Phone:607-763-6293
Mailing Address - Fax:607-763-6717
Practice Address - Street 1:200 FRONT ST
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1559
Practice Address - Country:US
Practice Address - Phone:607-658-1003
Practice Address - Fax:607-658-1006
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY526565163W00000X
NYF-334399363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02892717Medicaid
NY02892717Medicaid