=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144985664
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN DEMUTH APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2021
-----------------------------------------------------
Last Update Date | 11/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13129 PRESTWICK DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33579-7081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-484-7868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13129 PRESTWICK DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33579-7081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-484-7868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | APRN11016075
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------