Provider Demographics
NPI:1669502522
Name:OLIVER, SUSAN LEANNE (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEANNE
Last Name:OLIVER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LEANNE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:2510 LIMESTONE PKWY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2089
Practice Address - Country:US
Practice Address - Phone:770-219-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN153781363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA037059789DMedicaid
GAQ23290Medicare UPIN