MEDICARE: MRS. SUSANNE MARIE HARRIS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	5169961	NY

General Provider Information

NPI Number	:	1588683668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSANNE MARIE HARRIS RN

Provider Business Mailing Address
First Line	:	BOX 373
Second Line	:	3204 STATE RTE 52
City	:	WHITE SULPHUR SPRINGS
State	:	NY
Zip	:	12787
Country	:	US
Telephone Number	:	845-292-1624
Fax Number	:

Provider Business Practice Location Address
First Line	:	DAY TOP SWAN LAKE
Second Line	:
City	:	SWAN LAKE
State	:	NY
Zip	:	12783
Country	:	US
Telephone Number	:	845-292-6880
Fax Number	:	845-292-4873

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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