Basic Information
Provider Information
NPI: 1003290966
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: O'BRIEN
FirstName: SUSAN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: CRNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 205 BETA CIR
Address2:  
City: WERNERSVILLE
State: PA
PostalCode: 195651647
CountryCode: US
TelephoneNumber: 6104515640
FaxNumber:  
Practice Location
Address1: 2608 KEISER BLVD
Address2:  
City: WYOMISSING
State: PA
PostalCode: 196103333
CountryCode: US
TelephoneNumber: 6106855864
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/10/2015
LastUpdateDate: 07/10/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000XSP015090PAY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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