Provider Demographics
NPI:1932175825
Name:NIERENBERG, SUSAN LESLIE (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LESLIE
Last Name:NIERENBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1816
Mailing Address - Country:US
Mailing Address - Phone:716-875-2904
Mailing Address - Fax:716-875-6717
Practice Address - Street 1:155 LAWN AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1816
Practice Address - Country:US
Practice Address - Phone:716-875-2904
Practice Address - Fax:716-875-6717
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3307551363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
000560186001OtherCOMMUNITY CARE
S15509Medicare UPIN
X11691Medicare ID - Type Unspecified
00026522101OtherUNIVERA COMMERCIAL
00026522101OtherSENIOR CHOICE
NY01465154Medicaid
00026522101OtherUNIVERA HEALTHCARE TRADIT
000560186001OtherCB LABOR HEALTH
040426000322OtherFIDELIS
05169532OtherAETNA
000560186001OtherCHILD HEALTH PLUS FAMILY
040426000322OtherFIDELIS CHILD HEALTH
00026522101OtherASO
000560186001OtherCOMMUNITY BLUE STANDARD
000560186001OtherTRADITIONAL SECURE BLUE
040426000322OtherFIDELIS FAMILY HEALTH PLU
000560186001OtherBCBS
000560186001OtherCB ADVANTAGE
160975538OtherMAGNA CARE
3700166OtherGROUP HEALTH INS PPO CMP