Basic Information
Provider Information | |||||||||
NPI: | 1942597935 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERRINGTON | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.N. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RUCKER | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | R.N. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 300 W HOSPITAL RD | ||||||||
Address2: |   | ||||||||
City: | FORT GORDON | ||||||||
State: | GA | ||||||||
PostalCode: | 309055741 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067879355 | ||||||||
FaxNumber: | 7067870254 | ||||||||
Practice Location | |||||||||
Address1: | 300 W HOSPITAL RD | ||||||||
Address2: |   | ||||||||
City: | FORT GORDON | ||||||||
State: | GA | ||||||||
PostalCode: | 309055741 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067879355 | ||||||||
FaxNumber: | 7067870254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2011 | ||||||||
LastUpdateDate: | 06/29/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP2201X | RN040549 | GA | Y |   | Nursing Service Providers | Registered Nurse | Ambulatory Care |
No ID Information.