Provider Demographics
NPI:1578744462
Name:VARGAS, SUSAN L (RN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:L
Last Name:VARGAS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN LPN
Mailing Address - Street 1:48 SWAN LN
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-6804
Mailing Address - Country:US
Mailing Address - Phone:631-434-2467
Mailing Address - Fax:
Practice Address - Street 1:48 SWAN LN
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-6804
Practice Address - Country:US
Practice Address - Phone:631-434-2467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141459164W00000X
NY354149163WP0200X
NY3451491163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01512014Medicaid