Healthcare Provider Details

I. General information

NPI: 1972589588
Provider Name (Legal Business Name): MARY I RODDEN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 WESTERN AVE SUITE B-1
ALBANY NY
12203-3440
US

IV. Provider business mailing address

1444 WESTERN AVE SUITE B-1
ALBANY NY
12203-3440
US

V. Phone/Fax

Practice location:
  • Phone: 518-458-2611
  • Fax: 518-489-1914
Mailing address:
  • Phone: 518-458-2611
  • Fax: 518-489-1914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF333321
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: