Provider Demographics
NPI:1154818581
Name:KNIGHT, SUSAN ROBERTA
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ROBERTA
Last Name:KNIGHT
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 1:1990 JONES RD
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:NY
Mailing Address - Zip Code:14806-9723
Mailing Address - Country:US
Mailing Address - Phone:607-478-8475
Mailing Address - Fax:
Practice Address - Street 1:1990 JONES RD
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:NY
Practice Address - Zip Code:14806-9723
Practice Address - Country:US
Practice Address - Phone:607-478-8475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092041-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse