Provider Demographics
NPI:1346843182
Name:GOLDSWORTHY, SUSSAN LEE
Entity Type:Individual
Prefix:
First Name:SUSSAN
Middle Name:LEE
Last Name:GOLDSWORTHY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 S. ALAMO AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85707
Mailing Address - Country:US
Mailing Address - Phone:520-228-4357
Mailing Address - Fax:
Practice Address - Street 1:6811 BALLENGER RUN BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703
Practice Address - Country:US
Practice Address - Phone:478-225-7590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD257763363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health