Provider Demographics
NPI:1699380071
Name:SUSTACHE, CAROL A (LPN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:SUSTACHE
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 1:407 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2711
Mailing Address - Country:US
Mailing Address - Phone:315-396-3731
Mailing Address - Fax:
Practice Address - Street 1:407 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2711
Practice Address - Country:US
Practice Address - Phone:315-396-3731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277864164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty