Provider Demographics
NPI:1679858625
Name:IRELAND, SUSAN DAWN (NP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:DAWN
Last Name:IRELAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28963 LITTLE MACK AVE
Mailing Address - Street 2:SUITE101
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3017
Mailing Address - Country:US
Mailing Address - Phone:586-447-0700
Mailing Address - Fax:586-498-0707
Practice Address - Street 1:28963 LITTLE MACK AVE
Practice Address - Street 2:SUITE101
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3017
Practice Address - Country:US
Practice Address - Phone:586-447-0700
Practice Address - Fax:586-498-0707
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704140962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily