Provider Demographics
NPI:1255437273
Name:GERVASI, SUSAN H (WHCNP, BSN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:GERVASI
Suffix:
Gender:F
Credentials:WHCNP, BSN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13683 SE 127TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10100 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-786-8435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 083042345N7363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health