Provider Demographics
NPI:1720321276
Name:GAVIN, SUSAN R (RN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:GAVIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 DUNCAN AVE
Mailing Address - Street 2:
Mailing Address - City:CORNWALL ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12520-1412
Mailing Address - Country:US
Mailing Address - Phone:845-458-8292
Mailing Address - Fax:
Practice Address - Street 1:24 DUNCAN AVE
Practice Address - Street 2:
Practice Address - City:CORNWALL ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12520-1412
Practice Address - Country:US
Practice Address - Phone:845-458-8292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY456585372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion