Provider Demographics
NPI:1275552002
Name:STEVENSON, SUSAN LYNNE (RNC, MS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNNE
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:RNC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NEPONSET ST
Mailing Address - Street 2:WOT 2ND FL, STE C203
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-871-0780
Mailing Address - Fax:508-366-6744
Practice Address - Street 1:900 UNION ST
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-5408
Practice Address - Country:US
Practice Address - Phone:508-871-0780
Practice Address - Fax:508-366-6744
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN141700363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110020545AMedicaid
MAS79929Medicare UPIN
MANP1792Medicare ID - Type Unspecified