Basic Information
| Provider Information | |||||||||
| NPI: | 1447447008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | WALSH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRANT | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 67 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064181328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037321330 | ||||||||
| FaxNumber: | 2036796873 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064846244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039297331 | ||||||||
| FaxNumber: | 2039250330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 001755 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 364SG0600X | 001755 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology |
No ID Information.