Provider Demographics
NPI:1922540541
Name:JOHN, JULIE K
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:K
Last Name:JOHN
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 1:76 BRIDGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6204
Mailing Address - Country:US
Mailing Address - Phone:347-791-9109
Mailing Address - Fax:
Practice Address - Street 1:76 BRIDGETOWN ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6204
Practice Address - Country:US
Practice Address - Phone:347-791-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY708555174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist