Healthcare Provider Details

I. General information

NPI: 1699847004
Provider Name (Legal Business Name): LISA SUSSDORFF ATWOOD APRN, NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARY SUSSDORFF

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

PO BOX 9
PORT KENT NY
12975-0009
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-2370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number101-0025747
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: