Provider Demographics
NPI:1174934616
Name:ABRAHAM, SUSAMMA
Entity type:Individual
Prefix:
First Name:SUSAMMA
Middle Name:
Last Name:ABRAHAM
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 1:8045 WINCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2193
Mailing Address - Country:US
Mailing Address - Phone:718-739-5778
Mailing Address - Fax:718-523-2728
Practice Address - Street 1:8045 WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2193
Practice Address - Country:US
Practice Address - Phone:718-739-5778
Practice Address - Fax:718-523-2728
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY481818163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse