Provider Demographics
NPI:1710606918
Name:BLACK-JOHNSON, JOLUNDA
Entity Type:Individual
Prefix:
First Name:JOLUNDA
Middle Name:
Last Name:BLACK-JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 ROUTE 146 STE 101
Mailing Address - Street 2:
Mailing Address - City:HALFMOON
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3239
Mailing Address - Country:US
Mailing Address - Phone:518-373-3800
Mailing Address - Fax:
Practice Address - Street 1:400 PATROON CREEK BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-5014
Practice Address - Country:US
Practice Address - Phone:518-489-0044
Practice Address - Fax:518-489-3591
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349909363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily