Basic Information
Provider Information | |||||||||
NPI: | 1407815632 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEWART | ||||||||
FirstName: | SUSANNA | ||||||||
MiddleName: | KAY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LINDSEY | ||||||||
OtherFirstName: | SUSANNA | ||||||||
OtherMiddleName: | KAY | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 44008 | ||||||||
Address2: | UFJP PROVIDER ENROLLMENT | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322314008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042443199 | ||||||||
FaxNumber: | 9042443425 | ||||||||
Practice Location | |||||||||
Address1: | 655 W 8TH ST | ||||||||
Address2: | UFJP ANESTHESIA DEPT | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322096511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043935582 | ||||||||
FaxNumber: | 9042444908 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/17/2006 | ||||||||
LastUpdateDate: | 06/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209002176 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | ARNP9214586 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 2694441-00 | 05 | FL |   | MEDICAID | 685507863A | 05 | GA |   | MEDICAID |