Provider Demographics
NPI:1720522493
Name:SAMMONS, SUSAN R (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:SAMMONS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:R
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:203 WEST EMMITT AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690
Mailing Address - Country:US
Mailing Address - Phone:740-285-5034
Mailing Address - Fax:
Practice Address - Street 1:203 WEST EMMITT AVE
Practice Address - Street 2:SUITE C
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690
Practice Address - Country:US
Practice Address - Phone:740-285-5034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019780363LF0000X
KY3010929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK229660Medicare PIN
OHH548420Medicare PIN