Healthcare Provider Details

I. General information

NPI: 1518773795
Provider Name (Legal Business Name): AMANDA MARIE MEDINA RIVERA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 09/11/2025
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 NEW SCOTLAND AVE
ALBANY NY
12208-3409
US

IV. Provider business mailing address

371 1ST ST
TROY NY
12180-5302
US

V. Phone/Fax

Practice location:
  • Phone: 518-549-6616
  • Fax:
Mailing address:
  • Phone: 787-692-5889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number945341
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: