=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720616246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN ANTOINETTE PAPPAS APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2020
-----------------------------------------------------
Last Update Date | 03/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 GRANDVIEW AVE
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-573-7265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 582 MAIN ST S
-----------------------------------------------------
City | BETHLEHEM
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06751-2301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-233-1723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 8786
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------