Provider Demographics
NPI:1134888118
Name:PETERSON, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP - BC
Mailing Address - Street 1:18000 W 9 MILE RD STE 525
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4080
Mailing Address - Country:US
Mailing Address - Phone:248-327-6196
Mailing Address - Fax:
Practice Address - Street 1:18000 W 9 MILE RD STE 525
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4080
Practice Address - Country:US
Practice Address - Phone:248-327-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704310011363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704310011OtherNURSING LICENSE NUMBER