Provider Demographics
NPI:1386066009
Name:MALDONADO, SUSAN (LPN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MALDONADO
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:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:13439-0102
Mailing Address - Country:US
Mailing Address - Phone:607-264-3193
Mailing Address - Fax:
Practice Address - Street 1:5178 US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD CENTER
Practice Address - State:NY
Practice Address - Zip Code:13468-2100
Practice Address - Country:US
Practice Address - Phone:607-264-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270555164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse