Provider Demographics
NPI:1417500786
Name:TAMBASCO, SUZANNE RENEE (NP)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:RENEE
Last Name:TAMBASCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2870 PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2918
Mailing Address - Country:US
Mailing Address - Phone:770-309-5891
Mailing Address - Fax:
Practice Address - Street 1:210 TRILITH PKWY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4616
Practice Address - Country:US
Practice Address - Phone:770-309-5891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA155955363LP0808X
AZ259122363LP0808X
VA24185688363LP0808X
WV114662363LP0808X
FL11022333363LP0808X
CO0002821363LP0808X
OR202102650363LP0808X
NMCNP-63745363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health