Provider Demographics
NPI:1508835059
Name:DAMICO, SUSAN NICOLE (CFNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:NICOLE
Last Name:DAMICO
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14200 W CELEBRATE LIFE WAY
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-3007
Mailing Address - Country:US
Mailing Address - Phone:623-207-3904
Mailing Address - Fax:
Practice Address - Street 1:14200 W CELEBRATE LIFE WAY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3007
Practice Address - Country:US
Practice Address - Phone:623-207-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP006559B363L00000X
NYF331840-1363L00000X
AZTAP8519363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01932961Medicaid
PAP00199366OtherRR MEDICARE PIN
NYCC8362OtherRR MEDICARE GROUP
PACC9269OtherRR MEDICARE GROUP
PAGU039841OtherMEDICARE GROUP
NY500014013OtherRR MEDICARE PIN
PAGU039841OtherMEDICARE GROUP
NYCC5816Medicare ID - Type Unspecified
PA042152N82Medicare ID - Type Unspecified