Provider Demographics
NPI:1952484545
Name:DEFEDELE, SUSANNE G (PCNS)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:G
Last Name:DEFEDELE
Suffix:
Gender:F
Credentials:PCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HIGGINSON AVE
Mailing Address - Street 2:SUITE 107 D
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-2732
Mailing Address - Country:US
Mailing Address - Phone:401-723-7007
Mailing Address - Fax:
Practice Address - Street 1:101 HIGGINSON AVE
Practice Address - Street 2:SUITE 107 D
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-2732
Practice Address - Country:US
Practice Address - Phone:401-723-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPPNS00002364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI411680OtherBLUE CHIP OF RI
RI27266-5OtherBCBS OF RI
RISD51376Medicaid