Healthcare Provider Details

I. General information

NPI: 1770707317
Provider Name (Legal Business Name): SUSAN HERENDEEN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 W LAKE RD
CANANDAIGUA NY
14424-8953
US

IV. Provider business mailing address

2331 STATE ROUTE 21
CANANDAIGUA NY
14424-8715
US

V. Phone/Fax

Practice location:
  • Phone: 585-396-1602
  • Fax:
Mailing address:
  • Phone: 585-396-1165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number182310-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: