Provider Demographics
NPI:1326085945
Name:DIRKS, SUSAN (APRN-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:DIRKS
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 CONSTITUTION LN
Mailing Address - Street 2:SUITE 300A
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3694
Mailing Address - Country:US
Mailing Address - Phone:978-750-0755
Mailing Address - Fax:978-750-0766
Practice Address - Street 1:85 CONSTITUTION LN
Practice Address - Street 2:SUITE 300A
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3694
Practice Address - Country:US
Practice Address - Phone:978-750-0755
Practice Address - Fax:978-750-0766
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA201757363LA2200X, 363LG0600X, 364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2443OtherBC/BS PROVIDER NUMBER
MADINP2443Medicare ID - Type UnspecifiedPROVIDER NUMBER
MANP2443OtherBC/BS PROVIDER NUMBER