Provider Demographics
NPI:1144508581
Name:JAYNE, SUSANNE MARY (LPN)
Entity type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:MARY
Last Name:JAYNE
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 1:3410 WHITE ROAD
Mailing Address - Street 2:
Mailing Address - City:MORAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13118
Mailing Address - Country:US
Mailing Address - Phone:315-497-2625
Mailing Address - Fax:
Practice Address - Street 1:3410 WHITE ROAD
Practice Address - Street 2:
Practice Address - City:MORAVIA
Practice Address - State:NY
Practice Address - Zip Code:13118
Practice Address - Country:US
Practice Address - Phone:315-497-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280642-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse