Provider Demographics
NPI:1366642019
Name:BREAZEALE, SUSAN V (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:V
Last Name:BREAZEALE
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:PO BOX 2089
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-2089
Mailing Address - Country:US
Mailing Address - Phone:864-855-5104
Mailing Address - Fax:864-859-9362
Practice Address - Street 1:220 KEOWEE TRL
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1448
Practice Address - Country:US
Practice Address - Phone:864-653-4071
Practice Address - Fax:864-653-4074
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3805Medicaid
SCGP3805Medicaid
SCAA0147Medicare UPIN
SCAA01475844Medicare PIN