Healthcare Provider Details

I. General information

NPI: 1104919018
Provider Name (Legal Business Name): COLLEEN KEATING CUNNINGHAM ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 HOLLAND AVE
ALBANY NY
12208-3410
US

IV. Provider business mailing address

8 OLDE COACH RD
GLENMONT NY
12077-3057
US

V. Phone/Fax

Practice location:
  • Phone: 518-626-6098
  • Fax:
Mailing address:
  • Phone: 518-439-9544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303506-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: