Basic Information
Provider Information
NPI: 1003002601
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NURSE
FirstName: SUSAN
MiddleName: P
NamePrefix:  
NameSuffix:  
Credential: LPN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
164W00000X199450-1NYY Nursing Service ProvidersLicensed Practical Nurse 

ID Information
IDTypeStateIssuerDescription
0282407305NY MEDICAID


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