Provider Demographics
NPI:1043781909
Name:GREY-PARKES, SUSAN NICOLE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:NICOLE
Last Name:GREY-PARKES
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 1:9311 NW 55TH ST
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-7789
Mailing Address - Country:US
Mailing Address - Phone:305-297-3561
Mailing Address - Fax:
Practice Address - Street 1:12472 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2987
Practice Address - Country:US
Practice Address - Phone:305-297-3561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2019-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000272363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily