Provider Demographics
NPI:1245453398
Name:LAX, SUSAN PRISCILLA (APRN, BC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:PRISCILLA
Last Name:LAX
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3344
Mailing Address - Street 2:
Mailing Address - City:STOWE
Mailing Address - State:VT
Mailing Address - Zip Code:05672-3344
Mailing Address - Country:US
Mailing Address - Phone:617-372-5784
Mailing Address - Fax:
Practice Address - Street 1:782 MOUNTAIN RD STE D
Practice Address - Street 2:
Practice Address - City:STOWE
Practice Address - State:VT
Practice Address - Zip Code:05672-4629
Practice Address - Country:US
Practice Address - Phone:617-372-5784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT026.0135023163WP0808X
MA255146163WP0809X
VT101.0134152363LP0808X
MARN255146363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1033122Medicaid