Provider Demographics
NPI:1164579868
Name:SUSSI, GINA (ARNP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:SUSSI
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 POINTE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5525
Mailing Address - Country:US
Mailing Address - Phone:941-792-1404
Mailing Address - Fax:941-761-0712
Practice Address - Street 1:19621 COCHRAN BLVD STE 3
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2070
Practice Address - Country:US
Practice Address - Phone:941-321-4613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303615-1363LA2200X
FLAPRN9342254363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG1969ZMedicare PIN