Provider Demographics
NPI:1457071185
Name:O'SHAUGHNESSY, MADELINE NICOLE (DR)
Entity Type:Individual
Prefix:MISS
First Name:MADELINE
Middle Name:NICOLE
Last Name:O'SHAUGHNESSY
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOME DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4002
Mailing Address - Country:US
Mailing Address - Phone:631-316-4734
Mailing Address - Fax:
Practice Address - Street 1:1500 NY-112
Practice Address - Street 2:BUILDING 9
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-849-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist