Provider Demographics
NPI:1689662272
Name:DEMEULENAERE, SUSAN ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ANN
Last Name:DEMEULENAERE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:MOZDZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2601 ELECTRIC AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6587
Mailing Address - Country:US
Mailing Address - Phone:810-985-1819
Mailing Address - Fax:810-984-1160
Practice Address - Street 1:920 2ND AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-3318
Practice Address - Country:US
Practice Address - Phone:612-225-1512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-09
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704190745363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP34780011Medicare PIN
MIP22072Medicare UPIN