Provider Demographics
NPI:1093927212
Name:SEARS, SUSAN L
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:SEARS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 BOGGS LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2522
Mailing Address - Country:US
Mailing Address - Phone:859-228-2048
Mailing Address - Fax:
Practice Address - Street 1:1001 ACE DR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1327
Practice Address - Country:US
Practice Address - Phone:859-228-2048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1071441163W00000X
KY2603P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP13775Medicare UPIN
KY0777Medicare ID - Type UnspecifiedGROUP