Provider Demographics
NPI:1588712699
Name:FANELLI, SUZANNE NICOLE (RPA-C)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:NICOLE
Last Name:FANELLI
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SWAN DR
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7929
Mailing Address - Country:US
Mailing Address - Phone:516-308-4955
Mailing Address - Fax:
Practice Address - Street 1:18 SWAN DR
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-7929
Practice Address - Country:US
Practice Address - Phone:516-308-4955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant