Healthcare Provider Details

I. General information

NPI: 1366547358
Provider Name (Legal Business Name): SUSAN M BORDONARO DCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 VALLEY RD
MIDDLETOWN RI
02842-5237
US

IV. Provider business mailing address

102 VALLEY RD
MIDDLETOWN RI
02842-5237
US

V. Phone/Fax

Practice location:
  • Phone: 401-239-1800
  • Fax: 401-239-1801
Mailing address:
  • Phone: 401-239-1800
  • Fax: 401-239-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNPP34886
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberCAPRN00998
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: