Basic Information
| Provider Information | |||||||||
| NPI: | 1821742537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | SUSETTE | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857306970 | ||||||||
| FaxNumber: | 2257659196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1416 GOBBLER HEAD DR | ||||||||
| Address2: | |||||||||
| City: | BOGALUSA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704276091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857306970 | ||||||||
| FaxNumber: | 9857358883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2022 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 224267 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 224267 | 01 | LA | STATE LICENSE | OTHER |