Provider Demographics
NPI:1073824314
Name:SMITH, SUZANNE MARIE (MSN, RN, CNS, FNP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN, RN, CNS, FNP
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:MARIE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1225 E COOLSPRING AVE STE 300
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6312
Practice Address - Country:US
Practice Address - Phone:219-861-8161
Practice Address - Fax:219-861-8140
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28156702A363LF0000X
IN71003293A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200996360Medicaid
INM400023960OtherMEDICARE PTAN
MIMI4120001OtherMEDICARE PTAN