Healthcare Provider Details

I. General information

NPI: 1538812110
Provider Name (Legal Business Name): JILL MARIE FACTEAU I LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TIGER CIR
COHOES NY
12047-2399
US

IV. Provider business mailing address

1 TIGER CIR
COHOES NY
12047-2399
US

V. Phone/Fax

Practice location:
  • Phone: 518-237-9100
  • Fax: 518-833-7671
Mailing address:
  • Phone: 518-237-9100
  • Fax: 518-833-7671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number305301-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: