Provider Demographics
NPI:1760548283
Name:MIZGALA, SUSAN BARBARA
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BARBARA
Last Name:MIZGALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:USA MEDDAC ATTN: CREDENTIALS
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-4025
Mailing Address - Fax:315-772-9498
Practice Address - Street 1:USAHC-STUTTGART
Practice Address - Street 2:UNIT 30401
Practice Address - City:STUTTGART
Practice Address - State:GERMANY
Practice Address - Zip Code:APO
Practice Address - Country:DE
Practice Address - Phone:0711-680-7122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY537378-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN