Provider Demographics
NPI:1568956407
Name:VANKEUREN, SUSAN MARY
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:VANKEUREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 LEETES ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-6514
Mailing Address - Country:US
Mailing Address - Phone:203-481-3392
Mailing Address - Fax:
Practice Address - Street 1:22 LEETES ISLAND RD
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-6514
Practice Address - Country:US
Practice Address - Phone:203-481-3392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0007654183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist