Healthcare Provider Details

I. General information

NPI: 1518360635
Provider Name (Legal Business Name): ELIZABETH DEVEREUX FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 TROY ROAD FAMILY MEDICAL GROUP
RENSSELAER NY
12144-9756
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-286-1922
  • Fax:
Mailing address:
  • Phone: 518-525-5634
  • Fax: 518-649-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number339203
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number339203
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: