Provider Demographics
NPI:1689173569
Name:PAUL, SUSAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:PAUL
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 1:7925 WINCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2128
Mailing Address - Country:US
Mailing Address - Phone:718-264-7500
Mailing Address - Fax:
Practice Address - Street 1:7925 WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2128
Practice Address - Country:US
Practice Address - Phone:718-264-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY450801405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional