Healthcare Provider Details

I. General information

NPI: 1811294036
Provider Name (Legal Business Name): JUDE ANN KOBLENZER ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 BURDETT AVE
TROY NY
12180
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD STE 203
LATHAM NY
12110-2461
US

V. Phone/Fax

Practice location:
  • Phone: 518-270-3094
  • Fax:
Mailing address:
  • Phone: 518-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number305614
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: