Healthcare Provider Details

I. General information

NPI: 1760568133
Provider Name (Legal Business Name): SUSAN M CAWLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5364
US

IV. Provider business mailing address

3022 SW NEWBERRY COURT
PALM CITY FL
34990-3223
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-3088
  • Fax: 772-398-0041
Mailing address:
  • Phone: 772-288-3958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12134
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: