Provider Demographics
NPI:1629409198
Name:PELLETIER, SUSAN YVONNE
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:YVONNE
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:YVONNE
Other - Last Name:SHIPMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 CENTRAL DRIVE
Mailing Address - Street 2:SUITE 157
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022
Mailing Address - Country:US
Mailing Address - Phone:817-267-0909
Mailing Address - Fax:817-283-1868
Practice Address - Street 1:1600 CENTRAL DRIVE
Practice Address - Street 2:SUITE 157
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022
Practice Address - Country:US
Practice Address - Phone:817-267-0909
Practice Address - Fax:817-283-1868
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101300332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies