Healthcare Provider Details

I. General information

NPI: 1710542295
Provider Name (Legal Business Name): SUSAN MATHEW APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N LAKEMONT AVE
WINTER PARK FL
32792-3273
US

IV. Provider business mailing address

200 N LAKEMONT AVE
WINTER PARK FL
32792-3273
US

V. Phone/Fax

Practice location:
  • Phone: 407-646-7812
  • Fax:
Mailing address:
  • Phone: 407-646-7812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11001124
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: