Provider Demographics
NPI:1821429549
Name:IMWALLE, JULIE (MS ECSE ECE CSE CE)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:
Last Name:IMWALLE
Suffix:
Gender:F
Credentials:MS ECSE ECE CSE CE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RICKY RD
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5017
Mailing Address - Country:US
Mailing Address - Phone:631-553-9939
Mailing Address - Fax:
Practice Address - Street 1:15 RICKY RD
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-5017
Practice Address - Country:US
Practice Address - Phone:631-553-9939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY939497174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist