Provider Demographics
NPI:1982020475
Name:KRISSEL, SUSAN (CNM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KRISSEL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3180 MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4237
Practice Address - Country:US
Practice Address - Phone:203-374-0404
Practice Address - Fax:203-372-4167
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT389367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife