Provider Demographics
NPI:1851614259
Name:O'CONNELL, SUSAN BROOKE (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BROOKE
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-5131
Mailing Address - Country:US
Mailing Address - Phone:215-423-2030
Mailing Address - Fax:215-423-0476
Practice Address - Street 1:2623 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-5131
Practice Address - Country:US
Practice Address - Phone:215-423-2030
Practice Address - Fax:215-423-0476
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP004132D363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics