Healthcare Provider Details

I. General information

NPI: 1063505808
Provider Name (Legal Business Name): SUSAN H. MYZER CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4686 POUNCEY TRACT ROAD
GLEN ALLEN VA
23059
US

IV. Provider business mailing address

89 FOREST LN
KING WILLIAM VA
23086-3527
US

V. Phone/Fax

Practice location:
  • Phone: 804-422-5437
  • Fax:
Mailing address:
  • Phone: 480-221-7626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024172825
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: