Provider Demographics
NPI:1164494944
Name:COONCE, SUSAN D (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:D
Last Name:COONCE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4049 S CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5303
Mailing Address - Country:US
Mailing Address - Phone:417-890-5550
Mailing Address - Fax:417-889-6898
Practice Address - Street 1:4049 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5303
Practice Address - Country:US
Practice Address - Phone:417-890-5550
Practice Address - Fax:417-889-6898
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO83192163WG0000X
FLAPRN11007578363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425256617Medicaid
MOP28640Medicare UPIN