Provider Demographics
NPI:1669065264
Name:STRACK, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:STRACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 E CHESTNUT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-2762
Mailing Address - Country:US
Mailing Address - Phone:740-501-2318
Mailing Address - Fax:
Practice Address - Street 1:855 COSHOCTON AVE STE H-17
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1975
Practice Address - Country:US
Practice Address - Phone:740-224-3922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH025386363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily