Basic Information
Provider Information | |||||||||
NPI: | 1144389222 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIMASSA | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13523 BARRETT PARKWAY DRIVE | ||||||||
Address2: | SUITE 104 | ||||||||
City: | BALLWIN | ||||||||
State: | MO | ||||||||
PostalCode: | 630212802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6365492380 | ||||||||
FaxNumber: | 3145695974 | ||||||||
Practice Location | |||||||||
Address1: | 5319 HOAG DRIVE | ||||||||
Address2: |   | ||||||||
City: | ELYRIA | ||||||||
State: | OH | ||||||||
PostalCode: | 440351494 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4409306050 | ||||||||
FaxNumber: | 4409348882 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2006 | ||||||||
LastUpdateDate: | 02/10/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 42507 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | COA.03829-NA | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.