Provider Demographics
NPI:1245208263
Name:WARNER, SUE B (NP)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:B
Last Name:WARNER
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 1:485 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-5091
Mailing Address - Country:US
Mailing Address - Phone:617-972-5100
Mailing Address - Fax:
Practice Address - Street 1:485 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-5091
Practice Address - Country:US
Practice Address - Phone:617-972-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA157937363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPF856OtherHARVARD PILGRIM
MANP9897OtherBLUE CROSS
MAP36499Medicaid
MANP3372Medicare ID - Type Unspecified
MAP36499Medicaid