Provider Demographics
NPI:1952016396
Name:SUSTACHEK, ERIN BARDONNER (APRN)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:BARDONNER
Last Name:SUSTACHEK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:MARIE
Other - Last Name:BARDONNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-0307
Mailing Address - Country:US
Mailing Address - Phone:770-887-1668
Mailing Address - Fax:770-781-9937
Practice Address - Street 1:210 OAKSIDE LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-6417
Practice Address - Country:US
Practice Address - Phone:678-807-1050
Practice Address - Fax:770-720-7384
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP001149363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics