Provider Demographics
NPI:1003965120
Name:HARRIS, SUSAN A (APN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:HARRIS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 GREENE ROAD 657
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-7441
Mailing Address - Country:US
Mailing Address - Phone:870-215-1683
Mailing Address - Fax:
Practice Address - Street 1:801 GOLDSMITH RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-9509
Practice Address - Country:US
Practice Address - Phone:870-236-7782
Practice Address - Fax:870-236-9610
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01003ANP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148177758Medicaid