Healthcare Provider Details

I. General information

NPI: 1245453398
Provider Name (Legal Business Name): SUSAN PRISCILLA LAX APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 MOUNTAIN RD STE D
STOWE VT
05672-4629
US

IV. Provider business mailing address

PO BOX 3344
STOWE VT
05672-3344
US

V. Phone/Fax

Practice location:
  • Phone: 617-372-5784
  • Fax:
Mailing address:
  • Phone: 617-372-5784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number026.0135023
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number255146
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0134152
License Number StateVT
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN255146
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: