MEDICARE: SUSAN LEE MOENCH R.N.,M.S.,C.S.,N.P.

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	312927-1	NY

General Provider Information

NPI Number	:	1689875767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN LEE MOENCH R.N.,M.S.,C.S.,N.P.

Provider Business Mailing Address
First Line	:	35 STATE ST
Second Line	:
City	:	TULLY
State	:	NY
Zip	:	13159-3218
Country	:	US
Telephone Number	:	315-696-0264
Fax Number	:	315-696-0264

Provider Business Practice Location Address
First Line	:	35 STATE ST
Second Line	:
City	:	TULLY
State	:	NY
Zip	:	13159-3218
Country	:	US
Telephone Number	:	315-696-0264
Fax Number	:	315-696-0264

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

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	07/08/2007

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