Provider Demographics
NPI:1760455786
Name:MARKHAM, SUSAN (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MARKHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 SYCAMORE ST
Mailing Address - Street 2:SUITE 201-B
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4540
Mailing Address - Country:US
Mailing Address - Phone:860-659-0629
Mailing Address - Fax:860-714-6698
Practice Address - Street 1:31 SYCAMORE ST
Practice Address - Street 2:SUITE 201-B
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4540
Practice Address - Country:US
Practice Address - Phone:860-659-0629
Practice Address - Fax:860-714-6698
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001758363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001758OtherCT STATE LICENSE
CT001758OtherCT STATE LICENSE