Provider Demographics
NPI:1417654096
Name:PHELPS, MARY GAUDET (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GAUDET
Last Name:PHELPS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:PATRICIA
Other - Last Name:GAUDET
Other - Suffix:
Other - Last Name Type:Former Name
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:518-782-3700
Practice Address - Street 1:1882 NEW SCOTLAND RD STE 200
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-3627
Practice Address - Country:US
Practice Address - Phone:518-439-2460
Practice Address - Fax:518-439-3025
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349680363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily