Healthcare Provider Details

I. General information

NPI: 1952027955
Provider Name (Legal Business Name): RENEE ELIZABETH ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENEE ELIZABETH COUTURE

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 ST PATRICK PL
PORT HENRY NY
12974-1200
US

IV. Provider business mailing address

10 ST PATRICK PL
PORT HENRY NY
12974-1200
US

V. Phone/Fax

Practice location:
  • Phone: 518-546-3381
  • Fax: 518-546-3768
Mailing address:
  • Phone: 518-546-3381
  • Fax: 518-546-3768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1630473221
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: