Provider Demographics
NPI:1427262062
Name:LEISSLE, SUSANNE (LPN)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:LEISSLE
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 1:69 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WALLKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12589-3311
Mailing Address - Country:US
Mailing Address - Phone:845-895-3701
Mailing Address - Fax:
Practice Address - Street 1:69 LAKE RD
Practice Address - Street 2:
Practice Address - City:WALLKILL
Practice Address - State:NY
Practice Address - Zip Code:12589-3311
Practice Address - Country:US
Practice Address - Phone:845-895-3701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1149471164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01959062Medicaid