Provider Demographics
NPI:1821489212
Name:NYANTAKTI, SUZANA
Entity Type:Individual
Prefix:
First Name:SUZANA
Middle Name:
Last Name:NYANTAKTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUZANA
Other - Middle Name:
Other - Last Name:ADJETEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1421
Mailing Address - Country:US
Mailing Address - Phone:732-882-1057
Mailing Address - Fax:
Practice Address - Street 1:45 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1421
Practice Address - Country:US
Practice Address - Phone:732-882-1057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-07
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RW02285300183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician