Provider Demographics
NPI:1831454586
Name:DECOSTA, SUSAN (LPN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DECOSTA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1576 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3237
Mailing Address - Country:US
Mailing Address - Phone:516-572-5724
Mailing Address - Fax:
Practice Address - Street 1:50 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2519
Practice Address - Country:US
Practice Address - Phone:516-887-1200
Practice Address - Fax:516-593-2848
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131461164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse