Healthcare Provider Details

I. General information

NPI: 1659629483
Provider Name (Legal Business Name): SUZANNE TERSHAK TITHER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMBRIDGE ST FL 14
BOSTON MA
02114-2509
US

IV. Provider business mailing address

4 FRAKER LOOP
WHITEHALL MT
59759-8695
US

V. Phone/Fax

Practice location:
  • Phone: 888-731-8994
  • Fax:
Mailing address:
  • Phone: 443-223-9252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024170298
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201709803NP-PP
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704369510
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN267597
License Number StateMA
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number143721
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: