Provider Demographics
NPI:1649237918
Name:SUSHEREBA, ELIZABETH S (CNM)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:S
Last Name:SUSHEREBA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S MAIN ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-1477
Mailing Address - Country:US
Mailing Address - Phone:302-659-4520
Mailing Address - Fax:
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:SUITE 215
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1477
Practice Address - Country:US
Practice Address - Phone:302-659-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW010002367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001919801Medicaid
PA001919801Medicaid
PAP67617Medicare UPIN
DE003715C61Medicare PIN