Provider Demographics
NPI:1881797116
Name:POTTS-NULTY, SUSAN ELIZABETH (RN CRNP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:POTTS-NULTY
Suffix:
Gender:F
Credentials:RN CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8056 CRISPIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19136-2625
Mailing Address - Country:US
Mailing Address - Phone:215-823-5800
Mailing Address - Fax:215-823-4411
Practice Address - Street 1:VAMC UNIVERSITY AND WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-823-5800
Practice Address - Fax:215-823-4411
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP000997C363L00000X, 363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health