Provider Demographics
NPI:1518022045
Name:RODERICK, SUSAN H (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:H
Last Name:RODERICK
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1413
Mailing Address - Street 2:
Mailing Address - City:WELLFLEET
Mailing Address - State:MA
Mailing Address - Zip Code:02667
Mailing Address - Country:US
Mailing Address - Phone:508-240-0208
Mailing Address - Fax:508-240-0499
Practice Address - Street 1:49 HARRY KEMP WAY
Practice Address - Street 2:OUTER CAPE HEALTH
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1618
Practice Address - Country:US
Practice Address - Phone:508-487-9395
Practice Address - Fax:508-487-3285
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAMA113351363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP1127Medicare UPIN