Provider Demographics
NPI:1740601699
Name:WALTON, SUSAN (RN, NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 TERRY RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3811
Mailing Address - Country:US
Mailing Address - Phone:631-533-3009
Mailing Address - Fax:
Practice Address - Street 1:88 TERRY RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3811
Practice Address - Country:US
Practice Address - Phone:631-533-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY660859163W00000X
NY402433363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse