Provider Demographics
NPI:1174293583
Name:SUSEN, CALLISTA M
Entity Type:Individual
Prefix:
First Name:CALLISTA
Middle Name:M
Last Name:SUSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6985 NEXUS CT STE 107
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3186
Mailing Address - Country:US
Mailing Address - Phone:910-493-3999
Mailing Address - Fax:910-728-4644
Practice Address - Street 1:6985 NEXUS CT STE 107
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3186
Practice Address - Country:US
Practice Address - Phone:910-493-3999
Practice Address - Fax:910-728-4644
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-21-167101156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09162021Medicaid