Healthcare Provider Details

I. General information

NPI: 1124331228
Provider Name (Legal Business Name): ANITA FARRY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANITA SHACKELFORD R.N.

II. Dates (important events)

Enumeration Date: 07/17/2010
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 WHIPPLE WAY
ALTAMONT NY
12009-9204
US

IV. Provider business mailing address

PO BOX 3203
SCHENECTADY NY
12303-0203
US

V. Phone/Fax

Practice location:
  • Phone: 518-346-3100
  • Fax: 877-583-1284
Mailing address:
  • Phone: 518-346-3100
  • Fax: 877-583-1284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF334137-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: