Provider Demographics
NPI:1356590392
Name:VAN NEVEL, SUSAN KAY (PA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:VAN NEVEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:KAY
Other - Last Name:RUSCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2385 ABACO DR
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-2558
Mailing Address - Country:US
Mailing Address - Phone:850-499-5322
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1302
Practice Address - Country:US
Practice Address - Phone:850-883-9014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1197363A00000X
FLPA 9105988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant