Provider Demographics
NPI:1639923592
Name:PRIDDY, SUSAN RAE (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RAE
Last Name:PRIDDY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6192 BRIGHTON LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-7789
Mailing Address - Country:US
Mailing Address - Phone:850-712-2484
Mailing Address - Fax:
Practice Address - Street 1:1200 E JAMES LEE BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-3126
Practice Address - Country:US
Practice Address - Phone:850-689-5764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9207254163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator