Healthcare Provider Details

I. General information

NPI: 1912243502
Provider Name (Legal Business Name): MEDAYA USSERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 12/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 WOLF RD SUITE 100A
ALBANY NY
12205-6007
US

IV. Provider business mailing address

627 PRONDECE STREET
ALBANY NY
12208
US

V. Phone/Fax

Practice location:
  • Phone: 518-437-0152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number308030
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: