Provider Demographics
NPI:1528749801
Name:TULLY, SUSAN BERNIECE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BERNIECE
Last Name:TULLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 LEE ST
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-8750
Mailing Address - Country:US
Mailing Address - Phone:740-820-4540
Mailing Address - Fax:
Practice Address - Street 1:93 LEE ST
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-8750
Practice Address - Country:US
Practice Address - Phone:740-820-4540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide