Provider Demographics
NPI:1376107409
Name:NEWELL, SUSAN LONG
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LONG
Last Name:NEWELL
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 1:7441 HIGHWAY 9 S
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-9122
Mailing Address - Country:US
Mailing Address - Phone:662-419-8248
Mailing Address - Fax:
Practice Address - Street 1:3275 HIGHWAY 371 N
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855-7145
Practice Address - Country:US
Practice Address - Phone:662-282-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903617363LW0102X
MS897425163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE