Provider Demographics
NPI:1174709299
Name:MANZELLA, SUSAN J
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:J
Last Name:MANZELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:NY
Mailing Address - Zip Code:14025-9605
Mailing Address - Country:US
Mailing Address - Phone:716-941-8488
Mailing Address - Fax:
Practice Address - Street 1:959 BEACH RD
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:NY
Practice Address - Zip Code:14006-9702
Practice Address - Country:US
Practice Address - Phone:716-926-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011164174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist