Provider Demographics
NPI:1467422717
Name:DEWITT, SUSAN M (ARNP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:DEWITT
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 KINGSLEY AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4466
Mailing Address - Country:US
Mailing Address - Phone:904-272-6161
Mailing Address - Fax:
Practice Address - Street 1:1895 KINGSLEY AVENUE
Practice Address - Street 2:SUITE 303
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4466
Practice Address - Country:US
Practice Address - Phone:904-272-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1259822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4657ZMedicare ID - Type Unspecified
FLQ42703Medicare UPIN