Provider Demographics
NPI:1477033918
Name:ANTONELLI, SUSAN LACEY (NP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LACEY
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17876 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2602
Mailing Address - Country:US
Mailing Address - Phone:216-383-2222
Mailing Address - Fax:216-298-0241
Practice Address - Street 1:17876 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-2602
Practice Address - Country:US
Practice Address - Phone:216-383-2222
Practice Address - Fax:216-298-0241
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023456363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology