Provider Demographics
NPI:1609200443
Name:SHIVELY, SUSAN BERNADETTE (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BERNADETTE
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 MAPLEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-9726
Mailing Address - Country:US
Mailing Address - Phone:315-399-9161
Mailing Address - Fax:
Practice Address - Street 1:7420 MAPLEVIEW RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-9726
Practice Address - Country:US
Practice Address - Phone:315-399-9161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY441201-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse