Healthcare Provider Details

I. General information

NPI: 1740242668
Provider Name (Legal Business Name): EDITH CHRISTINE GROSS II
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 S MANNING BLVD SUITE 202
ALBANY NY
12208-1742
US

IV. Provider business mailing address

2154 LYNN ST
SCHENECTADY NY
12306-4231
US

V. Phone/Fax

Practice location:
  • Phone: 518-435-0842
  • Fax:
Mailing address:
  • Phone: 518-356-4422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303905
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: