Provider Demographics
NPI:1275770398
Name:INTHAVONG, SUSADA (APRN)
Entity Type:Individual
Prefix:
First Name:SUSADA
Middle Name:
Last Name:INTHAVONG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 NAEK RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-3942
Mailing Address - Country:US
Mailing Address - Phone:860-872-2289
Mailing Address - Fax:860-896-1425
Practice Address - Street 1:1504 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2711
Practice Address - Country:US
Practice Address - Phone:860-644-1523
Practice Address - Fax:860-648-9468
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003968363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003968OtherSTATE LICENSE