Provider Demographics
NPI:1194210542
Name:REILLY, SUSAN CATHERINE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CATHERINE
Last Name:REILLY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 GARLAND ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5066
Mailing Address - Country:US
Mailing Address - Phone:617-665-2555
Mailing Address - Fax:
Practice Address - Street 1:103 GARLAND ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-5066
Practice Address - Country:US
Practice Address - Phone:617-665-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN-241671163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse