Provider Demographics
NPI:1518027820
Name:SUSLECK, DACIA C (MSN, RN, CRNA)
Entity Type:Individual
Prefix:
First Name:DACIA
Middle Name:C
Last Name:SUSLECK
Suffix:
Gender:F
Credentials:MSN, RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-7400
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN PABLO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN74643163W00000X
TNAPN11180367500000X
VA0024175071367500000X
GARN176836367500000X
CANA95000653367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA341548053AMedicaid
4068478OtherBLUE CROSS BLUE SHIELD TN
NC8052092Medicaid
GAN348399OtherWELLCARE (GA MEDICAID)
P00098712OtherRAILROAD MEDICARE
AL009932455Medicaid
TN3633263Medicaid
TN3633263Medicaid