Provider Demographics
NPI:1205168333
Name:PENEPENT, SUSAN JEAN (RN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:PENEPENT
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 1:434B WINTHROP DR
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1739
Mailing Address - Country:US
Mailing Address - Phone:607-793-3755
Mailing Address - Fax:
Practice Address - Street 1:434B WINTHROP DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1739
Practice Address - Country:US
Practice Address - Phone:607-793-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402291163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse