Provider Demographics
NPI:1952648479
Name:LENNON, SUSAN JEAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:LENNON
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:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:PHOENICIA
Mailing Address - State:NY
Mailing Address - Zip Code:12464-0645
Mailing Address - Country:US
Mailing Address - Phone:845-688-5779
Mailing Address - Fax:
Practice Address - Street 1:5990 ROUTE 28
Practice Address - Street 2:
Practice Address - City:PHOENICIA
Practice Address - State:NY
Practice Address - Zip Code:12464
Practice Address - Country:US
Practice Address - Phone:845-688-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY510996163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse