Provider Demographics
NPI:1225402233
Name:DISSER, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DISSER
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 1:112 HOSPITAL LN
Mailing Address - Street 2:STE 110
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 HOSPITAL LN
Practice Address - Street 2:STE 110
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-2600
Practice Address - Country:US
Practice Address - Phone:765-762-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005869A363LF0000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily