Provider Demographics
NPI:1508925959
Name:SHEPPARD-NIEDHAMMER, SUEANNE (LPN)
Entity Type:Individual
Prefix:
First Name:SUEANNE
Middle Name:
Last Name:SHEPPARD-NIEDHAMMER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 WHITE BIRCH EST
Mailing Address - Street 2:
Mailing Address - City:FORT EDWARD
Mailing Address - State:NY
Mailing Address - Zip Code:12828-9273
Mailing Address - Country:US
Mailing Address - Phone:518-792-3258
Mailing Address - Fax:
Practice Address - Street 1:110 WHITE BIRCH EST
Practice Address - Street 2:
Practice Address - City:FORT EDWARD
Practice Address - State:NY
Practice Address - Zip Code:12828-9273
Practice Address - Country:US
Practice Address - Phone:518-792-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200223164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02315319Medicaid