Provider Demographics
NPI:1174614721
Name:SICOTTE, SUSAN M (CNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SICOTTE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5463
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:101 WEEMS ST
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-4062
Practice Address - Country:US
Practice Address - Phone:601-794-2224
Practice Address - Fax:601-794-6392
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR142560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00844126OtherRAILROAD MEDICARE
MS5726300OtherCIGNA
MS00126500Medicaid
MSP81464Medicare UPIN
MS500002227Medicare PIN