Provider Demographics
NPI:1841389541
Name:LAMBETH, MARY JEANNE
Entity Type:Individual
Prefix:
First Name:MARY JEANNE
Middle Name:
Last Name:LAMBETH
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:PO BOX 31094
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-1094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79 GLENRIDGE RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-4523
Practice Address - Country:US
Practice Address - Phone:518-952-8142
Practice Address - Fax:518-952-8109
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331382363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid
NYS85134Medicare PIN