Provider Demographics
NPI:1366614869
Name:HARRIS, SUSAN RENEE (FNP-C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:RENEE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 SHALE ST
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641-2926
Mailing Address - Country:US
Mailing Address - Phone:276-971-1030
Mailing Address - Fax:
Practice Address - Street 1:541 COMMUNITY COLLEGE RD
Practice Address - Street 2:DICKENSON HALL
Practice Address - City:CEDAR BLUFF
Practice Address - State:VA
Practice Address - Zip Code:24609
Practice Address - Country:US
Practice Address - Phone:276-596-4305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167677363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024167677OtherVA LICENSE