Healthcare Provider Details

I. General information

NPI: 1023309226
Provider Name (Legal Business Name): NICOLE SUSSER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 RAYBROOK ST SE STE 200
GRAND RAPIDS MI
49546-7718
US

IV. Provider business mailing address

2040 RAYBROOK ST SE STE 200
GRAND RAPIDS MI
49546-7718
US

V. Phone/Fax

Practice location:
  • Phone: 616-386-4260
  • Fax:
Mailing address:
  • Phone: 616-386-4260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number5101013675
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: