Healthcare Provider Details

I. General information

NPI: 1366887994
Provider Name (Legal Business Name): KATHY RISTAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 S PEARL ST
ALBANY NY
12202-1914
US

IV. Provider business mailing address

4 ATRIUM DR SUITE 100
ALBANY NY
12205-1441
US

V. Phone/Fax

Practice location:
  • Phone: 518-449-0100
  • Fax:
Mailing address:
  • Phone: 518-435-2740
  • Fax: 518-649-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number2151
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: