Provider Demographics
NPI:1538398292
Name:AVANT, SUZANNE TARA (PTA)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:TARA
Last Name:AVANT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4656 US HIGHWAY 117 S
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-3793
Mailing Address - Country:US
Mailing Address - Phone:910-470-2278
Mailing Address - Fax:
Practice Address - Street 1:4656 US HIGHWAY 117 S
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-3793
Practice Address - Country:US
Practice Address - Phone:910-470-2278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2058172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker