Healthcare Provider Details

I. General information

NPI: 1932162302
Provider Name (Legal Business Name): SUSAN GABRIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 E JOLLY RD
LANSING MI
48910-6818
US

IV. Provider business mailing address

375 APPLE TREE DR
IONIA MI
48846-7506
US

V. Phone/Fax

Practice location:
  • Phone: 517-346-8410
  • Fax:
Mailing address:
  • Phone: 616-527-1790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6801081022
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704136595
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: