Provider Demographics
NPI:1235462086
Name:GILLESPIE, SUSAN B (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:916-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2030 SUTTER PL
Practice Address - Street 2:SUITE 1000
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6212
Practice Address - Country:US
Practice Address - Phone:530-750-5904
Practice Address - Fax:530-750-5905
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP2071363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner