Healthcare Provider Details

I. General information

NPI: 1568000107
Provider Name (Legal Business Name): SUSIE WEAVER SEWELL RN, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 SOUTH BLVD
CHIPLEY FL
32428-1846
US

IV. Provider business mailing address

1338 SOUTH BLVD
CHIPLEY FL
32428-1846
US

V. Phone/Fax

Practice location:
  • Phone: 850-554-0046
  • Fax:
Mailing address:
  • Phone: 850-554-0046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN1328512
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: