Provider Demographics
NPI:1164896304
Name:SUE, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SUE
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 1:764 BRADY AVE
Mailing Address - Street 2:APT 231
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-2761
Mailing Address - Country:US
Mailing Address - Phone:917-795-3350
Mailing Address - Fax:
Practice Address - Street 1:764 BRADY AVE
Practice Address - Street 2:APT 231
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-2761
Practice Address - Country:US
Practice Address - Phone:917-795-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-28
Last Update Date:2015-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323817-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse