Provider Demographics
NPI:1578643896
Name:MOSS, SUSAN (CRNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N GRAND AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-3574
Mailing Address - Country:US
Mailing Address - Phone:985-851-1001
Mailing Address - Fax:985-851-1071
Practice Address - Street 1:165 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2767
Practice Address - Country:US
Practice Address - Phone:985-851-1001
Practice Address - Fax:985-851-1071
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA080012363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA99322Medicaid
LA1449172Medicaid