Provider Demographics
NPI:1720369630
Name:MENCHELL, SUSAN J
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:MENCHELL
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 1:25104 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-2724
Mailing Address - Country:US
Mailing Address - Phone:917-771-7715
Mailing Address - Fax:
Practice Address - Street 1:25104 71ST AVE
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-2724
Practice Address - Country:US
Practice Address - Phone:917-771-7715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY355846163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse