Provider Demographics
NPI:1639174535
Name:ST AMOUR, SUSAN
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:ST AMOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 STANLEY ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-6009
Mailing Address - Country:US
Mailing Address - Phone:508-324-3550
Mailing Address - Fax:508-676-5671
Practice Address - Street 1:386 STANLEY ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-6009
Practice Address - Country:US
Practice Address - Phone:508-675-1054
Practice Address - Fax:508-324-7777
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA124491363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0358380Medicaid
MA0358380Medicaid
MAS66208Medicare UPIN