Healthcare Provider Details

I. General information

NPI: 1124932470
Provider Name (Legal Business Name): ELISSA ANNE FAHNESTOCK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 NEW KARNER RD
ALBANY NY
12205-3809
US

IV. Provider business mailing address

35 SHAFER HEIGHTS RD
GLEN SPEY NY
12737-6151
US

V. Phone/Fax

Practice location:
  • Phone: 518-774-0945
  • Fax:
Mailing address:
  • Phone: 518-774-0945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LH0002X
TaxonomyHospice and Palliative Medicine (Anesthesiology) Physician
License NumberF360775-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: