Provider Demographics
NPI:1447750203
Name:WALD-THOMAS, SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WALD-THOMAS
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 1:11 NEVINS ST STE 405
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3514
Mailing Address - Country:US
Mailing Address - Phone:617-789-2646
Mailing Address - Fax:
Practice Address - Street 1:ST ELIZABETH MEDICAL CENTER
Practice Address - Street 2:736 CAMBRIDGE STREET MOB SUITE 405
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135
Practice Address - Country:US
Practice Address - Phone:617-789-2646
Practice Address - Fax:617-779-6378
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA180677363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health