Provider Demographics
NPI:1265501605
Name:VONDERHEIDE, SUSAN G (APRN, PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:VONDERHEIDE
Suffix:
Gender:F
Credentials:APRN, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3B TAGGART DR
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-5592
Mailing Address - Country:US
Mailing Address - Phone:603-891-1152
Mailing Address - Fax:603-881-9744
Practice Address - Street 1:3B TAGGART DR
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-5592
Practice Address - Country:US
Practice Address - Phone:603-891-1152
Practice Address - Fax:603-881-9744
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH392103TC0700X
NH066468-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3005954Medicaid
NH3005954Medicaid