Provider Demographics
NPI:1437872207
Name:MANDERVILLE, BLAIRE (RN)
Entity Type:Individual
Prefix:
First Name:BLAIRE
Middle Name:
Last Name:MANDERVILLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 AIKEN AVE # A
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-2522
Mailing Address - Country:US
Mailing Address - Phone:518-227-9989
Mailing Address - Fax:
Practice Address - Street 1:40 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1481
Practice Address - Country:US
Practice Address - Phone:518-453-6707
Practice Address - Fax:518-453-2519
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY827512163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse