Healthcare Provider Details

I. General information

NPI: 1477436079
Provider Name (Legal Business Name): ANTHONY RAYMOND MAINELLA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 ACADEMY RD
ALBANY NY
12208-3103
US

IV. Provider business mailing address

105 HYDE BLVD
BALLSTON SPA NY
12020-1600
US

V. Phone/Fax

Practice location:
  • Phone: 518-912-4808
  • Fax: 518-514-1383
Mailing address:
  • Phone: 518-461-9531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number743550
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: