Healthcare Provider Details

I. General information

NPI: 1275005514
Provider Name (Legal Business Name): VANESSA LYNN PALMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SHARRON AVE
PLATTSBURGH NY
12901-4700
US

IV. Provider business mailing address

79 GLENRIDGE RD
GLENVILLE NY
12302-4523
US

V. Phone/Fax

Practice location:
  • Phone: 518-561-1447
  • Fax: 518-562-8812
Mailing address:
  • Phone: 518-952-8408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01420800
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: