Provider Demographics
NPI:1932670510
Name:BEATTIE, SUSAN LYNN (APRN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNN
Last Name:BEATTIE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LYNN
Other - Last Name:OPPENHEIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3313
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR # 1E
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:213-123-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-08
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000475363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNI964OtherMEDICARE HF
FL107344700Medicaid