Provider Demographics
NPI:1285075465
Name:SCIAMETTA, SUSANJOHNNA (RN)
Entity type:Individual
Prefix:
First Name:SUSANJOHNNA
Middle Name:
Last Name:SCIAMETTA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WILLIAMS BLVD
Mailing Address - Street 2:APART. 1B
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2447
Mailing Address - Country:US
Mailing Address - Phone:631-327-2455
Mailing Address - Fax:
Practice Address - Street 1:3 WILLIAMS BLVD
Practice Address - Street 2:APART. 1B
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2447
Practice Address - Country:US
Practice Address - Phone:631-327-2455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY593391-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY593391-1Medicaid