Provider Demographics
NPI:1407984636
Name:MORRISSEY, SUSAN (NP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:MORRISSEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:850 HARRISON AVE
Mailing Address - Street 2:YACC BN-C7
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST
Practice Address - Street 2:SHAPIRO 5, SUITE B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-414-5951
Practice Address - Fax:617-414-1577
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN115188363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110018302AMedicaid
MA110018302AMedicaid
MANP1409Medicare PIN