Provider Demographics
NPI:1184040156
Name:FEDELE, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FEDELE
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 1:6715 PARADISE PARK
Mailing Address - Street 2:
Mailing Address - City:SARANAC
Mailing Address - State:MI
Mailing Address - Zip Code:48881-8785
Mailing Address - Country:US
Mailing Address - Phone:616-402-0756
Mailing Address - Fax:
Practice Address - Street 1:6715 PARADISE PARK
Practice Address - Street 2:
Practice Address - City:SARANAC
Practice Address - State:MI
Practice Address - Zip Code:48881-8785
Practice Address - Country:US
Practice Address - Phone:616-402-0756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2218592471M2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammography