Provider Demographics
NPI:1730150590
Name:DAVIS, SUSAN L (FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MANNING AVE
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-5768
Mailing Address - Country:US
Mailing Address - Phone:978-847-0110
Mailing Address - Fax:978-665-5959
Practice Address - Street 1:20 WORCESTER CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1312
Practice Address - Country:US
Practice Address - Phone:508-368-3140
Practice Address - Fax:508-368-3144
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA166356363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
47953OtherFALLON COMMUNITY HEALTH
500007983OtherRAILROAD MEDICARE
NP1842OtherBLUE SHIELD INDEMNITY
042472266OtherTHREE RIVERS
042472266OtherTRICARE CHAMPUS
AA3609OtherHARVARD PILGRIM HEALTH
042472266OtherPRIVATE HEALTHCARE SYSTEM
NP1842OtherBLUE CARE ELECT
S82167Medicare UPIN
NP1842OtherBLUE CARE ELECT
500007983OtherRAILROAD MEDICARE