Basic Information
| Provider Information | |||||||||
| NPI: | 1730150590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 MANNING AVE | ||||||||
| Address2: | |||||||||
| City: | LEOMINSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014535768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788470110 | ||||||||
| FaxNumber: | 9786655959 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 WORCESTER CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683140 | ||||||||
| FaxNumber: | 5083683144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 166356 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 47953 | 01 | FALLON COMMUNITY HEALTH | OTHER | 500007983 | 01 | RAILROAD MEDICARE | OTHER | NP1842 | 01 | BLUE SHIELD INDEMNITY | OTHER | 042472266 | 01 | THREE RIVERS | OTHER | 042472266 | 01 | TRICARE CHAMPUS | OTHER | AA3609 | 01 | HARVARD PILGRIM HEALTH | OTHER | 042472266 | 01 | PRIVATE HEALTHCARE SYSTEM | OTHER | NP1842 | 01 | BLUE CARE ELECT | OTHER |