Provider Demographics
NPI:1497060560
Name:WASSELUK, SUSAN COLLI (NP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:COLLI
Last Name:WASSELUK
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 1:105 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-5205
Mailing Address - Country:US
Mailing Address - Phone:413-478-2054
Mailing Address - Fax:
Practice Address - Street 1:105 PARK ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5205
Practice Address - Country:US
Practice Address - Phone:413-478-2054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2267834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily