Provider Demographics
NPI:1609007194
Name:BROWN, SUSAN A (ARDMS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:BROWN
Suffix:
Gender:F
Credentials:ARDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 NW LAKE WHITNEY PL
Mailing Address - Street 2:SUITE #106
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1615
Mailing Address - Country:US
Mailing Address - Phone:772-785-8000
Mailing Address - Fax:772-785-8150
Practice Address - Street 1:501 NW LAKE WHITNEY PL
Practice Address - Street 2:SUITE #106
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1615
Practice Address - Country:US
Practice Address - Phone:772-785-8000
Practice Address - Fax:772-785-8150
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL143072471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV2026OtherBLUE SHIELD
FL510001100Medicaid