Provider Demographics
NPI:1225480247
Name:MANN, SUSAN (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1090
Mailing Address - Country:US
Mailing Address - Phone:631-909-8697
Mailing Address - Fax:631-909-8697
Practice Address - Street 1:2 CLAY ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1090
Practice Address - Country:US
Practice Address - Phone:631-909-8697
Practice Address - Fax:631-909-8697
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY496033163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY496033OtherRN LICENSE