Healthcare Provider Details

I. General information

NPI: 1962489658
Provider Name (Legal Business Name): MARY ANNE MARTIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ANNE MARTIN BARRY

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 LAFAYETTE ST
SCHENECTADY NY
12305-2408
US

IV. Provider business mailing address

1462 ERIE BLVD SUITE 2
SCHENECTADY NY
12305-1026
US

V. Phone/Fax

Practice location:
  • Phone: 518-243-3300
  • Fax: 518-377-9151
Mailing address:
  • Phone: 518-243-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number400240
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: