Provider Demographics
NPI:1376186254
Name:KOFFLER, SUSAN (MS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KOFFLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 WARWICK RD
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1832
Mailing Address - Country:US
Mailing Address - Phone:516-978-3416
Mailing Address - Fax:
Practice Address - Street 1:1651 WARWICK RD
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1832
Practice Address - Country:US
Practice Address - Phone:516-978-3416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor