Provider Demographics
NPI:1295734903
Name:EBY, SUSAN SANFORD (APN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:SANFORD
Last Name:EBY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3344 SHEFFIELD CT
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-3522
Mailing Address - Country:US
Mailing Address - Phone:865-254-3984
Mailing Address - Fax:
Practice Address - Street 1:3344 SHEFFIELD CT
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3522
Practice Address - Country:US
Practice Address - Phone:865-254-3984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN101035363LP0808X
TNAPN7016363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3908549Medicaid
TN3908549OtherMEDICARE ID--UNSPECIFIED TYPE
TN3908549Medicaid