Healthcare Provider Details

I. General information

NPI: 1841389541
Provider Name (Legal Business Name): MARY JEANNE LAMBETH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 GLENRIDGE RD
GLENVILLE NY
12302-4523
US

IV. Provider business mailing address

PO BOX 31094
HARTFORD CT
06150-1094
US

V. Phone/Fax

Practice location:
  • Phone: 518-952-8142
  • Fax: 518-952-8109
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number331382
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: