Provider Demographics
NPI:1003571621
Name:IM, SUSANNA
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:IM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 PEREGRINE DR
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-1661
Mailing Address - Country:US
Mailing Address - Phone:856-246-2294
Mailing Address - Fax:
Practice Address - Street 1:435 HURFFVILLE - CROSS KEYS RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08080
Practice Address - Country:US
Practice Address - Phone:856-582-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01244400363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner