Provider Demographics
NPI:1790263358
Name:POWELL, SUZETTE
Entity Type:Individual
Prefix:
First Name:SUZETTE
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19807 HOLLIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-1229
Mailing Address - Country:US
Mailing Address - Phone:954-914-5408
Mailing Address - Fax:
Practice Address - Street 1:19807 HOLLIS AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-1229
Practice Address - Country:US
Practice Address - Phone:954-914-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308345-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health