Healthcare Provider Details

I. General information

NPI: 1447866413
Provider Name (Legal Business Name): ANTANAYA I WALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 COOPER HILL RD
WYNANTSKILL NY
12198-2906
US

IV. Provider business mailing address

614 COOPER HILL RD
WYNANTSKILL NY
12198-2906
US

V. Phone/Fax

Practice location:
  • Phone: 518-283-6500
  • Fax:
Mailing address:
  • Phone: 518-283-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number115889
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: