Provider Demographics
NPI:1952493397
Name:HAGUE, SUSAN B (ARNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:HAGUE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 LITHIA CENTER LN
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-5676
Mailing Address - Country:US
Mailing Address - Phone:813-662-0123
Mailing Address - Fax:813-689-2166
Practice Address - Street 1:2237 LITHIA CENTER LN
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-5676
Practice Address - Country:US
Practice Address - Phone:813-662-0123
Practice Address - Fax:813-689-2166
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1359722363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR88091Medicare UPIN
Y4790ZMedicare ID - Type Unspecified