Provider Demographics
NPI:1457181042
Name:KURILLA, SUSAN MARGARET
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARGARET
Last Name:KURILLA
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 1:18409 CUB CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-8339
Mailing Address - Country:US
Mailing Address - Phone:570-239-2694
Mailing Address - Fax:
Practice Address - Street 1:1404 GOLF PARK DR
Practice Address - Street 2:
Practice Address - City:LAKE ARIEL
Practice Address - State:PA
Practice Address - Zip Code:18436-4252
Practice Address - Country:US
Practice Address - Phone:570-698-5647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027286363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health