Provider Demographics
NPI:1679663769
Name:FINE, SUSAN A (ARNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:FINE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 E NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5459
Mailing Address - Country:US
Mailing Address - Phone:321-984-4405
Mailing Address - Fax:321-728-3001
Practice Address - Street 1:719 E NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5459
Practice Address - Country:US
Practice Address - Phone:321-984-4405
Practice Address - Fax:321-728-3001
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN163458367500000X
FLARNP9311568367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2482595Medicaid
OHFI7331771Medicare PIN