Provider Demographics
NPI:1407688666
Name:STIVALO, SUSAN MARIE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:STIVALO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 OLD MAMARONECK RD APT 2G
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1738
Mailing Address - Country:US
Mailing Address - Phone:914-325-8414
Mailing Address - Fax:
Practice Address - Street 1:10 OLD MAMARONECK RD APT 2G
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1738
Practice Address - Country:US
Practice Address - Phone:914-325-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11034446363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty