Provider Demographics
NPI:1760634885
Name:COLLIGON, SUSANNE M (NP)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:M
Last Name:COLLIGON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:C
Other - Last Name:FESSICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:5855 BREMO RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1930
Mailing Address - Country:US
Mailing Address - Phone:804-288-2673
Mailing Address - Fax:804-285-5572
Practice Address - Street 1:5855 BREMO RD
Practice Address - Street 2:SUITE 403
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1930
Practice Address - Country:US
Practice Address - Phone:804-288-2673
Practice Address - Fax:804-285-5572
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167970363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN
VA1760634885Medicaid
P00802487Medicare PIN
VA022587C48Medicare PIN