Provider Demographics
NPI:1114472123
Name:KING, SUSAN (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 RYE ST
Mailing Address - Street 2:
Mailing Address - City:BROAD BROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06016-9563
Mailing Address - Country:US
Mailing Address - Phone:869-798-7413
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:860-494-5784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006690363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology