Provider Demographics
NPI:1184374456
Name:OBERLY, SUSANNAH LYN
Entity type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:LYN
Last Name:OBERLY
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 1:28 CONNECTICUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14867-9296
Mailing Address - Country:US
Mailing Address - Phone:607-342-3333
Mailing Address - Fax:
Practice Address - Street 1:27005 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1402
Practice Address - Country:US
Practice Address - Phone:718-470-7873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program