Healthcare Provider Details

I. General information

NPI: 1336161884
Provider Name (Legal Business Name): SUSAN LEE REILLY ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR 5L
LEBANON NH
03756-1000
US

IV. Provider business mailing address

12 BOWERS RD.
HARTLAND VT
05048-0295
US

V. Phone/Fax

Practice location:
  • Phone: 603-653-9302
  • Fax: 603-650-0902
Mailing address:
  • Phone: 802-436-2564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number015400-23-04
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: