Provider Demographics
NPI:1467756619
Name:LA BAGNARA, SUSAN (APN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:LA BAGNARA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BERGEN ST
Mailing Address - Street 2:F342
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2496
Mailing Address - Country:US
Mailing Address - Phone:973-972-0658
Mailing Address - Fax:973-972-1340
Practice Address - Street 1:150 BERGEN ST
Practice Address - Street 2:F342
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2496
Practice Address - Country:US
Practice Address - Phone:973-972-0658
Practice Address - Fax:973-972-1340
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NC05172800364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics