Provider Demographics
NPI:1700043411
Name:HENDERSON, SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 COLTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-3108
Mailing Address - Country:US
Mailing Address - Phone:631-678-2972
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:SUITE 216
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-8809
Practice Address - Country:US
Practice Address - Phone:631-475-5511
Practice Address - Fax:631-475-5544
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30304827363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health