Provider Demographics
NPI:1457314650
Name:RANDALL-MANTELLA, SUSAN M (RNNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:RANDALL-MANTELLA
Suffix:
Gender:F
Credentials:RNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 MEDICAL CENTER DR
Mailing Address - Street 2:POD C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6600
Mailing Address - Country:US
Mailing Address - Phone:315-329-4975
Mailing Address - Fax:315-329-4970
Practice Address - Street 1:4117 MEDICAL CENTER DR
Practice Address - Street 2:POD C
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6600
Practice Address - Country:US
Practice Address - Phone:315-329-4975
Practice Address - Fax:315-329-4970
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330714363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02245370Medicaid
NY02245370Medicaid
NYJ400037547Medicare PIN
NYR89981Medicare UPIN