Provider Demographics
NPI:1881644631
Name:IZZO, SUSAN CHARMAINE (NP)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:CHARMAINE
Last Name:IZZO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:CZARNECKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:29 NAEK RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-3942
Mailing Address - Country:US
Mailing Address - Phone:860-872-2289
Mailing Address - Fax:860-896-1425
Practice Address - Street 1:520 HARTFORD TPKE
Practice Address - Street 2:SUITE N
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5037
Practice Address - Country:US
Practice Address - Phone:860-872-8321
Practice Address - Fax:860-875-6271
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003300363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004261062Medicaid
CT004261062Medicaid
CT500001734Medicare PIN