Provider Demographics
NPI:1891814422
Name:BERKOWITZ, SUSAN J (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:BERKOWITZ
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:BRAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:114 TOWNPARK DR NW
Mailing Address - Street 2:SUITE 240
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3715
Mailing Address - Country:US
Mailing Address - Phone:770-952-8612
Mailing Address - Fax:678-803-6944
Practice Address - Street 1:1620 MULKEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1104
Practice Address - Country:US
Practice Address - Phone:770-948-3774
Practice Address - Fax:770-739-9609
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN101050363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003146736Medicaid
GA003146736Medicaid