Healthcare Provider Details

I. General information

NPI: 1750345773
Provider Name (Legal Business Name): SUSU HANKHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

IV. Provider business mailing address

6520 FORT CAROLINE RD
JACKSONVILLE FL
32277-2044
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7765
  • Fax:
Mailing address:
  • Phone: 904-745-3618
  • Fax: 904-722-4271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number74058
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: