Provider Demographics
NPI:1629393558
Name:GAYNOR, SUZANNE (LAC)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:GAYNOR
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4565 PRAIRIE TRL
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-5840
Mailing Address - Country:US
Mailing Address - Phone:203-505-4506
Mailing Address - Fax:
Practice Address - Street 1:1590 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1164
Practice Address - Country:US
Practice Address - Phone:928-227-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-03
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0640171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist