Provider Demographics
NPI:1598102964
Name:WIRTH, SUSANNE
Entity Type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:
Last Name:WIRTH
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 1:424 N ALLEGHANY AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-3437
Mailing Address - Country:US
Mailing Address - Phone:631-891-5507
Mailing Address - Fax:
Practice Address - Street 1:424 N ALLEGHANY AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-3437
Practice Address - Country:US
Practice Address - Phone:631-891-5507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-25
Last Update Date:2013-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY469653163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health