MEDICARE: MISS SUSAN CLAIRE DICKENSON APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	003361	CT

General Provider Information

NPI Number	:	1366563355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SUSAN CLAIRE DICKENSON APRN

Provider Business Mailing Address
First Line	:	1322 AVON BOULEVARD
Second Line	:
City	:	CHESHIRE
State	:	CT
Zip	:	06410
Country	:	US
Telephone Number	:	203-271-0048
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 YORK STREET
Second Line	:	YALE NEW HAVEN HOSPITAL
City	:	NEW HAVEN
State	:	CT
Zip	:	06504
Country	:	US
Telephone Number	:	203-688-2323
Fax Number	:	203-785-5833

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/08/2007

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