Provider Demographics
NPI:1912525122
Name:SUSANA, MARIEL ALTAGRACIA (NP)
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:ALTAGRACIA
Last Name:SUSANA
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 1:10440 NW 74TH ST UNIT 305
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2462
Mailing Address - Country:US
Mailing Address - Phone:347-853-6393
Mailing Address - Fax:
Practice Address - Street 1:944 S MILITARY TRL
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-3910
Practice Address - Country:US
Practice Address - Phone:561-425-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007448363LA2200X
FLAPRN11007448363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health