Provider Demographics
NPI:1093963175
Name:LATTANZI, SUSAN Y (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:Y
Last Name:LATTANZI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:JEANNE
Other - Last Name:YETMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 STAFFORD STREET
Mailing Address - Street 2:SUITES 101, 154 & 161
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2431
Mailing Address - Country:US
Mailing Address - Phone:413-732-1928
Mailing Address - Fax:413-734-1716
Practice Address - Street 1:300 STAFFORD STREET
Practice Address - Street 2:SUITES 101, 154 & 161
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2431
Practice Address - Country:US
Practice Address - Phone:413-732-1928
Practice Address - Fax:413-734-1716
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA168570363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087924AMedicaid