Healthcare Provider Details

I. General information

NPI: 1073802906
Provider Name (Legal Business Name): SUSAN CULLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RETREAT AVE
HARTFORD CT
06109-4337
US

IV. Provider business mailing address

101 MANNING DR UNC HEALTH CARE
CHAPEL HILL NC
27514
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-7200
  • Fax:
Mailing address:
  • Phone: 919-966-1550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number007531
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number007531
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: