Healthcare Provider Details

I. General information

NPI: 1033394283
Provider Name (Legal Business Name): SUSAN MALTON OKKERSE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN ELIZABETH MALTON CRNA

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 NORTH TRYON STREET
CHARLOTTE NC
28262-3300
US

IV. Provider business mailing address

PO BOX 560727 ANESTHESIA DEPARTMENT
CHARLOTTE NC
28256-0727
US

V. Phone/Fax

Practice location:
  • Phone: 704-863-5665
  • Fax: 704-863-5848
Mailing address:
  • Phone: 704-863-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number31372
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: