Provider Demographics
NPI:1356654792
Name:ODOHERTY, MARY PATRICIA (LPN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:ODOHERTY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13665 68TH DRIVE
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11367
Mailing Address - Country:US
Mailing Address - Phone:718-897-1581
Mailing Address - Fax:
Practice Address - Street 1:13665 68TH DR
Practice Address - Street 2:
Practice Address - City:KEW GARDENS HILLS
Practice Address - State:NY
Practice Address - Zip Code:11367-1619
Practice Address - Country:US
Practice Address - Phone:718-897-1581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239868-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse