Provider Demographics
NPI:1326317132
Name:SWAINE, SUSAN JO (REGISTERED NURSE)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:JO
Last Name:SWAINE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 CASEMENT AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-5001
Mailing Address - Country:US
Mailing Address - Phone:631-234-1418
Mailing Address - Fax:
Practice Address - Street 1:50 TIMBERLINE DR
Practice Address - Street 2:EAST ELEM.SCHOOL
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4803
Practice Address - Country:US
Practice Address - Phone:631-434-2244
Practice Address - Fax:631-434-2186
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY431417-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool