Provider Demographics
NPI:1891825840
Name:MANTELLO, HEATHER M (FNP)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:M
Last Name:MANTELLO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:M
Other - Last Name:KEPNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:314 S MANNING BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1708
Mailing Address - Country:US
Mailing Address - Phone:518-437-5970
Mailing Address - Fax:518-437-5975
Practice Address - Street 1:314 S MANNING BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1708
Practice Address - Country:US
Practice Address - Phone:518-437-5970
Practice Address - Fax:518-437-5975
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334824363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03083483Medicaid
NYJ400296933Medicare PIN