Healthcare Provider Details

I. General information

NPI: 1871908335
Provider Name (Legal Business Name): MARYBETH BOSSOLINI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 JORDAN RD SUITE 200
TROY NY
12180-8309
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD SUITE 203
LATHAM NY
12110-2442
US

V. Phone/Fax

Practice location:
  • Phone: 518-274-0476
  • Fax: 518-274-0497
Mailing address:
  • Phone: 518-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number338889
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: