Provider Demographics
NPI:1790706257
Name:DEMICCO, SUSAN KATHERYN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KATHERYN
Last Name:DEMICCO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 BOSTON POST RD
Mailing Address - Street 2:STE. 670
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3536
Mailing Address - Country:US
Mailing Address - Phone:203-783-1831
Mailing Address - Fax:
Practice Address - Street 1:831 BOSTON POST RD
Practice Address - Street 2:STE. 670
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3536
Practice Address - Country:US
Practice Address - Phone:203-783-1831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRNA21303367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007057147Medicare PIN
MANA1189Medicare PIN
MANA118901Medicare PIN