Healthcare Provider Details

I. General information

NPI: 1679512396
Provider Name (Legal Business Name): JANET MARY TIBERIA PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANET MARY CARMODY PNP

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 MADISON AVE PEDIATRICS
ALBANY NY
12208-2248
US

IV. Provider business mailing address

2 BAYBERRY CIR
POESTENKILL NY
12140-2309
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-2445
  • Fax: 518-475-7069
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF380750
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: