Provider Demographics
NPI:1144985664
Name:DEMUTH, SUSAN (APRN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DEMUTH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13129 PRESTWICK DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-7081
Mailing Address - Country:US
Mailing Address - Phone:813-484-7868
Mailing Address - Fax:
Practice Address - Street 1:13129 PRESTWICK DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-7081
Practice Address - Country:US
Practice Address - Phone:813-484-7868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11016075363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner