Provider Demographics
NPI:1598948820
Name:EUSTACE, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:EUSTACE
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 1:106 DAFFODIL DR
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-1806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 COLLEGE AVE STE 3
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1154
Practice Address - Country:US
Practice Address - Phone:607-733-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260115164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse