Provider Demographics
NPI:1952468894
Name:MACDOUGAL, JULIE F (NP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:F
Last Name:MACDOUGAL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:F
Other - Last Name:CHRISTOPHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1125 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12204-2505
Mailing Address - Country:US
Mailing Address - Phone:518-433-3739
Mailing Address - Fax:
Practice Address - Street 1:1125 BROADWAY
Practice Address - Street 2:
Practice Address - City:MENANDS
Practice Address - State:NY
Practice Address - Zip Code:12204-2505
Practice Address - Country:US
Practice Address - Phone:518-433-3739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334957363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02847776Medicaid
NYRB3225Medicare PIN
NY02847776Medicaid