Provider Demographics
NPI:1821699257
Name:MADDOX, SUSAN M
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MADDOX
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 1:4522 W LOOP 281 LOT 25
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-5867
Mailing Address - Country:US
Mailing Address - Phone:903-926-6517
Mailing Address - Fax:
Practice Address - Street 1:4522 W LOOP 281 LOT 25
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-5867
Practice Address - Country:US
Practice Address - Phone:903-926-6517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX894813163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse