Provider Demographics
NPI:1124226931
Name:LAVELLE, SUSAN MARIA (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIA
Last Name:LAVELLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8690 PETALUMA HILL RD
Mailing Address - Street 2:
Mailing Address - City:PENNGROVE
Mailing Address - State:CA
Mailing Address - Zip Code:94951-8734
Mailing Address - Country:US
Mailing Address - Phone:707-992-0030
Mailing Address - Fax:
Practice Address - Street 1:16319 THIRD STREET
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446
Practice Address - Country:US
Practice Address - Phone:707-869-2849
Practice Address - Fax:707-869-1477
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 17209363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health