Basic Information
| Provider Information | |||||||||
| NPI: | 1386049385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
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| Practice Location | |||||||||
| Address1: | 279 TROY RD | ||||||||
| Address2: | |||||||||
| City: | RENSSELAER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121449518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182861922 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2014 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 339091 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03993955 | 05 | NY | MEDICAID |