MEDICARE: SUSAN ROBERTA TUSSEY FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	VP003542B	PA

General Provider Information

NPI Number	:	1053307504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN ROBERTA TUSSEY FNP

Provider Business Mailing Address
First Line	:	4525 CAMPUS AVE
Second Line	:	#8
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-1127
Country	:	US
Telephone Number	:	808-228-5661
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 CAMPUS AVE
Second Line	:	#8
City	:	SAN DIEGO
State	:	CA
Zip	:	92116
Country	:	US
Telephone Number	:	808-228-5661
Fax Number	:	808-257-5653

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	05/06/2010

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