=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093055709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN ELIZABETH SHIRATO DNP, CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2013
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 BOWMAN DR STE E385
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-9638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-840-4534
-----------------------------------------------------
Fax | 856-762-2853
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 LIPPINCOTT DR STE 410
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-4197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-840-4534
-----------------------------------------------------
Fax | 856-762-2853
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ00472800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------