Provider Demographics
NPI:1790439297
Name:MAUNDA, DOROTHY ADHIAMB0
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ADHIAMB0
Last Name:MAUNDA
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 1:77 W BARNEY ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1040
Mailing Address - Country:US
Mailing Address - Phone:315-287-1000
Mailing Address - Fax:
Practice Address - Street 1:84 WAVERLY ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1607
Practice Address - Country:US
Practice Address - Phone:315-261-3541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF403984-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health