Provider Demographics
NPI:1427186949
Name:SMALL, SUSANNE K (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:K
Last Name:SMALL
Suffix:
Gender:F
Credentials:CRNA
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 1188
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-5009
Mailing Address - Country:US
Mailing Address - Phone:270-824-3682
Mailing Address - Fax:270-824-3675
Practice Address - Street 1:900 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1644
Practice Address - Country:US
Practice Address - Phone:270-824-3682
Practice Address - Fax:270-824-3675
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137090367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00944104OtherMEDICARE RAILROAD FOR 5363
MO8298OtherHEALTHCARE USA (GROUP)
IA0563130Medicaid
430079704OtherRAILROAD MEDICARE
MO915942007Medicaid
MO80172OtherHEALTHCARE USA
CG4336OtherRAILROAD MEDICARE
IA0976845Medicaid
KYP400021749Medicare PIN
KYP00944104OtherMEDICARE RAILROAD FOR 5363