Provider Demographics
NPI:1942467337
Name:PRATHER, SUSAN (CFNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PRATHER
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 FRIARS POINT RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-9734
Mailing Address - Country:US
Mailing Address - Phone:662-624-4316
Mailing Address - Fax:662-627-2758
Practice Address - Street 1:580 FRIARS POINT RD
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-9734
Practice Address - Country:US
Practice Address - Phone:662-624-4316
Practice Address - Fax:662-621-1151
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874318363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09983311Medicaid
MS302I508194Medicare PIN