Provider Demographics
NPI:1295147718
Name:MOFFITT, SUZETT
Entity type:Individual
Prefix:
First Name:SUZETT
Middle Name:
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 N TIBBS AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-2457
Mailing Address - Country:US
Mailing Address - Phone:317-755-7664
Mailing Address - Fax:317-955-7567
Practice Address - Street 1:2401 N TIBBS AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-2457
Practice Address - Country:US
Practice Address - Phone:317-755-7664
Practice Address - Fax:317-955-7567
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN14-013067-1251G00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN14-013067-1OtherINDIANA STATE DEPARTMENT OF HEALTH
IN201172830AOtherINDIANA STATE DEPARTMENT OF HEALTH
INA0H1301OSSTKEANOtherCMS EHR CERTIFICATION ID
IN829814297OtherCCR REGISTRATION
IN76110000OtherDEPARTMENT OF ADMINISTRATION