Provider Demographics
NPI:1023762499
Name:KRUGER, SUSAN CECELIA (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CECELIA
Last Name:KRUGER
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:CECELIA
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:2452 ROUTE 9
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020
Mailing Address - Country:US
Mailing Address - Phone:518-426-2801
Mailing Address - Fax:518-514-1383
Practice Address - Street 1:60 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3103
Practice Address - Country:US
Practice Address - Phone:518-426-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY854834163W00000X, 163WG0000X
NY238140164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY854834OtherNYSED
NY1023762499Medicaid