Basic Information
Provider Information | |||||||||
NPI: | 1043527153 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HILTY | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8569 | ||||||||
Address2: |   | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 341018569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2396240400 | ||||||||
FaxNumber: | 2396240464 | ||||||||
Practice Location | |||||||||
Address1: | 311 9TH ST N STE 110 | ||||||||
Address2: |   | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 34102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2396248490 | ||||||||
FaxNumber: | 2396248491 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2010 | ||||||||
LastUpdateDate: | 06/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN9418951 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 6SUCU | 01 | FL | FLORIDA BLUE | OTHER | 019601700 | 05 | FL |   | MEDICAID |