Provider Demographics
NPI:1265518633
Name:CHASSON, SUSAN P (APRN/CNM)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:CHASSON
Suffix:
Gender:F
Credentials:APRN/CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 WEST 940 NORTH
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-357-7930
Mailing Address - Fax:801-357-7014
Practice Address - Street 1:475 WEST 940 NORTH
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-357-7930
Practice Address - Fax:801-357-7014
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT219067-4405363LF0000X
UT219067-4402363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854058788-D5889Medicaid
R92022Medicare UPIN
UT942854058788-D5889Medicaid
UT005532633Medicare ID - Type Unspecified