Basic Information
| Provider Information | |||||||||
| NPI: | 1881920734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | NEIDLINGER | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 386 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313290386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127546451 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1451 GA HIGHWAY 21 S H | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313295244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127541035 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2009 | ||||||||
| LastUpdateDate: | 02/01/2018 | ||||||||
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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 | RN113434NP | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 003146075C | 05 | GA | MEDICAID | 003146075A | 05 | GA | MEDICAID | 003146075G | 05 | GA | MEDICAID | 003146075B | 05 | GA | MEDICAID | 003146075D | 05 | GA | MEDICAID | 003146075E | 05 | GA | MEDICAID | 003146075F | 05 | GA | MEDICAID |