Healthcare Provider Details

I. General information

NPI: 1245354190
Provider Name (Legal Business Name): SUSAN LANGMACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 WATERMAN AVE
EAST PROVIDENCE RI
02914-2427
US

IV. Provider business mailing address

35 SHERMAN AVE
BRISTOL RI
02809-4524
US

V. Phone/Fax

Practice location:
  • Phone: 401-435-7800
  • Fax:
Mailing address:
  • Phone: 401-253-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number13627
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: