Provider Demographics
NPI:1720137151
Name:MAHLKE, SUSAN JANE (NP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JANE
Last Name:MAHLKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 LOCKWOOD STREET
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893
Mailing Address - Country:US
Mailing Address - Phone:401-821-0787
Mailing Address - Fax:
Practice Address - Street 1:277 WATERMAN STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-331-7777
Practice Address - Fax:401-354-4445
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP37228363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI312543OtherBLUE CROSS BLUE SHIELD
RISM59428Medicaid
RI007058185Medicare ID - Type Unspecified