Provider Demographics
NPI:1144233420
Name:NIFENECKER, SUSAN (NPP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NIFENECKER
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-2606
Mailing Address - Country:US
Mailing Address - Phone:516-221-3030
Mailing Address - Fax:516-221-1013
Practice Address - Street 1:2146 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-2606
Practice Address - Country:US
Practice Address - Phone:516-221-3030
Practice Address - Fax:516-221-1013
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400714-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003933339Medicaid
NYW02651Medicare PIN