Provider Demographics
NPI:1578211835
Name:ROMAN, SUSANNE ALICE MARIE
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:ALICE MARIE
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:ALICE MARIE
Other - Last Name:FECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAIDEN NAME
Mailing Address - Street 1:903 WOODLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-6341
Mailing Address - Country:US
Mailing Address - Phone:334-655-0037
Mailing Address - Fax:
Practice Address - Street 1:4300 W MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1306
Practice Address - Country:US
Practice Address - Phone:334-793-9564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-156884363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily