Provider Demographics
NPI:1922144047
Name:KALISH, SUSAN R (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:R
Last Name:KALISH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 FAIRFIELD DRIVE
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746
Mailing Address - Country:US
Mailing Address - Phone:631-242-8448
Mailing Address - Fax:
Practice Address - Street 1:35 RAMSEY ROAD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725
Practice Address - Country:US
Practice Address - Phone:631-543-8663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1534981164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02059814Medicaid
NYR8YOtherETIN