Provider Demographics
NPI:1114501251
Name:HIBBERT, SUSAN (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HIBBERT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BOURNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1235 HARROD AVENUE
Mailing Address - Street 2:APARTMENT 2R
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-2765
Mailing Address - Country:US
Mailing Address - Phone:917-721-1955
Mailing Address - Fax:347-708-1532
Practice Address - Street 1:1235 HARROD AVENUE
Practice Address - Street 2:APARTMENT 2R
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-2765
Practice Address - Country:US
Practice Address - Phone:917-721-1955
Practice Address - Fax:347-708-1532
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY661946163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse