1093924425 NPI number — MS. SUSAN S SPAUSE F.N.P.

Table of content: MS. SUSAN S SPAUSE F.N.P. (NPI 1093924425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093924425 NPI number — MS. SUSAN S SPAUSE F.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPAUSE
Provider First Name:
SUSAN
Provider Middle Name:
S
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
F.N.P.
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:
1093924425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17907 EBB TIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWES
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19958-4183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-300-5725
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 N FRONT ST BLDG 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEAFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19973-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-886-2277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2007

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: 363LF0000X , with the licence number:  LG-0000721 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: F332500 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: LG-0000721 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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