Basic Information
| Provider Information | |||||||||
| NPI: | 1659767648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULA | ||||||||
| FirstName: | SUZANA | ||||||||
| MiddleName: | X | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SULA | ||||||||
| OtherFirstName: | SUZANA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3404 34TH AVE # APTD5 | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111061174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3472558330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 263 BLUE POINT | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314196737 | ||||||||
| FaxNumber: | 6318683498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2015 | ||||||||
| LastUpdateDate: | 04/07/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 319892 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 319892 | 01 | NY | THE UNIVERSITY OF THE STATE OF NY. EDUCATION DEPARTMENT | OTHER |