1093931719 NPI number — MRS. SUSAN D EARL NP

Table of content: MRS. SUSAN D EARL NP (NPI 1093931719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093931719 NPI number — MRS. SUSAN D EARL NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EARL
Provider First Name:
SUSAN
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093931719
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
890 W POPLAR AVE STE 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLIERVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38017-2582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-221-8621
Provider Business Mailing Address Fax Number:
901-221-8631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 W POPLAR AVE STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLIERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38017-2582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-221-8621
Provider Business Practice Location Address Fax Number:
901-221-8631
Provider Enumeration Date:
04/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  12687 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)