Provider Demographics
NPI:1831534270
Name:MIANULLI, SUSAN LYNN (MS)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LYNN
Last Name:MIANULLI
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-1325
Mailing Address - Country:US
Mailing Address - Phone:516-224-4199
Mailing Address - Fax:
Practice Address - Street 1:47 HUMPHREY DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4022
Practice Address - Country:US
Practice Address - Phone:516-921-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116269021174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist