Basic Information
| Provider Information | |||||||||
| NPI: | 1477552347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAIN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN-BC, PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11503 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374012503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237783274 | ||||||||
| FaxNumber: | 4237782255 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 BLACKFORD STREET | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374031405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237786476 | ||||||||
| FaxNumber: | 4237784232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 10/07/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP2953602 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 13768 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 451755976A | 05 | GA | MEDICAID | 306729700 | 05 | FL | MEDICAID |