Provider Demographics
NPI:1770081325
Name:BATES FONDA, TINA MARIE
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:BATES FONDA
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 1:305 FISHER BLVD APT D
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-2455
Mailing Address - Country:US
Mailing Address - Phone:518-549-6670
Mailing Address - Fax:
Practice Address - Street 1:75 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3409
Practice Address - Country:US
Practice Address - Phone:518-549-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY510611163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health