Provider Demographics
NPI:1083135461
Name:SUZANNE CARLISLE STEBENNE
Entity Type:Organization
Organization Name:SUZANNE CARLISLE STEBENNE
Other - Org Name:IDEAL PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLISLE STEBENNE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN FNP-BC
Authorized Official - Phone:202-394-9166
Mailing Address - Street 1:468 ROUTE 12
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05048-8109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 HOLIDAY DR STE 4
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-2044
Practice Address - Country:US
Practice Address - Phone:202-394-9166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0110101363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty