Healthcare Provider Details

I. General information

NPI: 1396847075
Provider Name (Legal Business Name): SUSAN LEA THIEVON M.S., APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN LEA CATES M.S. ARNP

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 ROUTE 66
RANDOLPH VT
05060-7718
US

IV. Provider business mailing address

1422 ROUTE 66
RANDOLPH VT
05060-7718
US

V. Phone/Fax

Practice location:
  • Phone: 802-728-7100
  • Fax:
Mailing address:
  • Phone: 802-728-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number049495-23
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0494952303
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0134836
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: