Healthcare Provider Details

I. General information

NPI: 1730918905
Provider Name (Legal Business Name): ALYSSA MARIA BALLANTYNE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 WESTERN AVE STE D
ALBANY NY
12203-3458
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-452-0587
  • Fax: 518-218-0152
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number354267
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: