Provider Demographics
NPI:1639627573
Name:LEDER, SUSANNA LOUISE (LPN)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:LOUISE
Last Name:LEDER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4707 VENICE RD LOT 9
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-1500
Mailing Address - Country:US
Mailing Address - Phone:419-357-7715
Mailing Address - Fax:
Practice Address - Street 1:4707 VENICE RD LOT 9
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-1500
Practice Address - Country:US
Practice Address - Phone:419-357-7715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.097263-MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse