Provider Demographics
NPI:1336496025
Name:MEMMELAAR, ANGELA (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MEMMELAAR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:2125 RIVER RD
Practice Address - Street 2:SUITE 303
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309-1135
Practice Address - Country:US
Practice Address - Phone:518-382-8350
Practice Address - Fax:518-382-0345
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY306051363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03494497Medicaid
NY121109000005OtherFIDELIS CARE NY
NY03494497Medicaid