Provider Demographics
NPI:1821566415
Name:NEWPORT, SU-ANN
Entity Type:Individual
Prefix:
First Name:SU-ANN
Middle Name:
Last Name:NEWPORT
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 1:474 N YELLOW SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2463
Mailing Address - Country:US
Mailing Address - Phone:937-399-9500
Mailing Address - Fax:937-342-4242
Practice Address - Street 1:474 N YELLOW SPRINGS ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2463
Practice Address - Country:US
Practice Address - Phone:937-399-9500
Practice Address - Fax:937-342-4242
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNS.03726364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health