Provider Demographics
NPI:1154053346
Name:SUSAINATHAN, MARYLAILA D
Entity Type:Individual
Prefix:MRS
First Name:MARYLAILA
Middle Name:D
Last Name:SUSAINATHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 KREIDER DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2160
Mailing Address - Country:US
Mailing Address - Phone:314-324-4698
Mailing Address - Fax:
Practice Address - Street 1:435 KREIDER DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-2160
Practice Address - Country:US
Practice Address - Phone:314-324-4698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant