Healthcare Provider Details

I. General information

NPI: 1023762499
Provider Name (Legal Business Name): SUSAN CECELIA KRUGER REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN CECELIA MCCORMICK LPN

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 09/25/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 ACADEMY RD
ALBANY NY
12208-3103
US

IV. Provider business mailing address

2452 ROUTE 9 SUITE 206
MALTA NY
12020
US

V. Phone/Fax

Practice location:
  • Phone: 518-426-2725
  • Fax:
Mailing address:
  • Phone: 518-426-2801
  • Fax: 518-514-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number854834
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number238140
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number854834
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: