Provider Demographics
NPI:1932641412
Name:SUSO, SHARON JORDAN
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:JORDAN
Last Name:SUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHARON
Other - Middle Name:MELINDA
Other - Last Name:NEAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNA
Mailing Address - Street 1:5453 DEERFIELD TRAIL
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-3173
Mailing Address - Country:US
Mailing Address - Phone:404-587-0008
Mailing Address - Fax:
Practice Address - Street 1:5453 DEERFIELD TRAIL
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-3173
Practice Address - Country:US
Practice Address - Phone:404-587-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0000008047376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACN0000008047OtherGA NURSE AIDE REGISTRY