Healthcare Provider Details

I. General information

NPI: 1467614230
Provider Name (Legal Business Name): SUSAN JANE PONIVAS RN, ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 IVY ST FL 2
ELMIRA NY
14905-1646
US

IV. Provider business mailing address

709 N JUSTICE ST STE A
HENDERSONVILLE NC
28791-3455
US

V. Phone/Fax

Practice location:
  • Phone: 607-737-4333
  • Fax: 607-737-4271
Mailing address:
  • Phone: 828-697-7377
  • Fax: 828-697-7380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5015271
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number304914
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: