Healthcare Provider Details

I. General information

NPI: 1548219157
Provider Name (Legal Business Name): SUSAN L THERRIAULT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 S MAIN ST
WOLFEBORO NH
03894-4411
US

IV. Provider business mailing address

240 S MAIN ST
WOLFEBORO NH
03894-4411
US

V. Phone/Fax

Practice location:
  • Phone: 603-569-7574
  • Fax: 603-569-7582
Mailing address:
  • Phone: 603-569-7574
  • Fax: 603-569-7582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9132
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: