Healthcare Provider Details

I. General information

NPI: 1194718387
Provider Name (Legal Business Name): DEBORAH ANNE BODY DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 STATE ROUTE 30
TUPPER LAKE NY
12986-2502
US

IV. Provider business mailing address

2445 STATE ROUTE 30
TUPPER LAKE NY
12986-2502
US

V. Phone/Fax

Practice location:
  • Phone: 518-554-8087
  • Fax: 518-359-4133
Mailing address:
  • Phone: 518-554-8087
  • Fax: 518-359-4133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number438972
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number331877
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: