Provider Demographics
NPI:1902379688
Name:KING, ALIDA M (FNP)
Entity Type:Individual
Prefix:
First Name:ALIDA
Middle Name:M
Last Name:KING
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ALIDA
Other - Middle Name:M
Other - Last Name:BREAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:161 CAREY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-7821
Practice Address - Country:US
Practice Address - Phone:518-824-8610
Practice Address - Fax:518-824-2390
Is Sole Proprietor?:No
Enumeration Date:2019-01-06
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY607329163W00000X
NYF345975363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05439267Medicaid