Provider Demographics
NPI:1235120833
Name:DALTON, ANNE (NP)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:DALTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 FIRELANE 7
Mailing Address - Street 2:
Mailing Address - City:KING FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:13081
Mailing Address - Country:US
Mailing Address - Phone:315-364-8676
Mailing Address - Fax:
Practice Address - Street 1:699 FIRELANE 7
Practice Address - Street 2:
Practice Address - City:KING FERRY
Practice Address - State:NY
Practice Address - Zip Code:13081
Practice Address - Country:US
Practice Address - Phone:315-364-8676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332139363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02045912Medicaid
S89926Medicare UPIN
NY02045912Medicaid