Provider Demographics
NPI:1720291537
Name:VALENZA, SUSAN (DISPENSING OPTICIAN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:VALENZA
Suffix:
Gender:F
Credentials:DISPENSING OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2925
Mailing Address - Country:US
Mailing Address - Phone:973-667-0444
Mailing Address - Fax:973-667-2353
Practice Address - Street 1:148 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2925
Practice Address - Country:US
Practice Address - Phone:973-667-0444
Practice Address - Fax:973-667-2353
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00091000156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2903008Medicaid
NJ2903008Medicaid