Provider Demographics
NPI:1376785592
Name:STOCK, SUSAN JANE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:STOCK
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 1:91-2301 OLD FT WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3602
Mailing Address - Country:US
Mailing Address - Phone:808-671-8511
Mailing Address - Fax:808-677-2570
Practice Address - Street 1:91-2301 OLD FT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3602
Practice Address - Country:US
Practice Address - Phone:808-671-8511
Practice Address - Fax:808-677-2570
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15326163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health