Provider Demographics
NPI:1619907722
Name:DRUST, SUSAN LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:DRUST
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LYNN
Other - Last Name:DE BARBARAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:5100 GAY ST
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-5724
Mailing Address - Country:US
Mailing Address - Phone:231-327-9544
Mailing Address - Fax:
Practice Address - Street 1:493 W NORTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3748
Practice Address - Country:US
Practice Address - Phone:231-375-5251
Practice Address - Fax:231-375-8439
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704168366163WG0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS64229Medicare UPIN
MIP11820001Medicare ID - Type Unspecified