Healthcare Provider Details

I. General information

NPI: 1851391205
Provider Name (Legal Business Name): SUSAN GAIL COHEN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 WASHINGTON AVE
BENNINGTON VT
05201-2312
US

IV. Provider business mailing address

209 WASHINGTON AVE
BENNINGTON VT
05201-2312
US

V. Phone/Fax

Practice location:
  • Phone: 802-442-0158
  • Fax: 802-442-0160
Mailing address:
  • Phone: 802-442-0158
  • Fax: 802-442-0160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1010021887
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: