Provider Demographics
NPI:1750310116
Name:DE VIVIO, SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DE VIVIO
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 1:2201 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1859
Mailing Address - Country:US
Mailing Address - Phone:516-572-6177
Mailing Address - Fax:
Practice Address - Street 1:2201 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1859
Practice Address - Country:US
Practice Address - Phone:516-572-6177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292543363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02724541Medicaid
Q65706Medicare UPIN
NY02724541Medicaid