Provider Demographics
NPI:1134201817
Name:LUNDGREN, SUSAN M (FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5835 HARBOUR VIEW BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2601
Practice Address - Country:US
Practice Address - Phone:757-397-4200
Practice Address - Fax:757-397-3872
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165171363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1134201817Medicaid
VA020664R53Medicare PIN