Provider Demographics
NPI:1841558731
Name:MAZZELLA, SUSAN MARIE (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:MAZZELLA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 DARNELL LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1955
Mailing Address - Country:US
Mailing Address - Phone:718-356-5523
Mailing Address - Fax:
Practice Address - Street 1:1911 RICHMOND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3913
Practice Address - Country:US
Practice Address - Phone:718-420-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY501254-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse