Basic Information
| Provider Information | |||||||||
| NPI: | 1003002601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NURSE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13319 CHAPMAN CORNERS RD | ||||||||
| Address2: | |||||||||
| City: | RED CREEK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131433187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3158791099 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13319 CHAPMAN CORNERS RD | ||||||||
| Address2: | |||||||||
| City: | RED CREEK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131433187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3158791099 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 09/18/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 199450-1 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 02824073 | 05 | NY | MEDICAID |