Healthcare Provider Details

I. General information

NPI: 1255442869
Provider Name (Legal Business Name): SUSAN L. BATES RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CHARLTON ROAD
BALLSTON LAKE NY
12019-2547
US

IV. Provider business mailing address

112 CHARLTON ROAD
BALLSTON LAKE NY
12019-2547
US

V. Phone/Fax

Practice location:
  • Phone: 518-399-7723
  • Fax: 518-399-7753
Mailing address:
  • Phone: 518-399-7723
  • Fax: 518-399-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number427188
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: