Provider Demographics
NPI:1982640603
Name:JEWELL, SUSAN D (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:JEWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:1603 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1087
Practice Address - Country:US
Practice Address - Phone:502-451-5955
Practice Address - Fax:502-451-5925
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001152A363LF0000X
KY3003470363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY112515OtherSIHO - NICC
KY78013067Medicaid
KY000000651171OtherANTHEM - NICC
IN200351560Medicaid
KYP400016499Medicare PIN
P34820Medicare UPIN
IN200351560Medicaid