Provider Demographics
NPI:1922280817
Name:GAGNON, SUSAN ELIZABETH
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:GAGNON
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:PO BOX 9014
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-0014
Mailing Address - Country:US
Mailing Address - Phone:401-859-3335
Mailing Address - Fax:401-246-4655
Practice Address - Street 1:652 GEORGE WASHINGTON HWY UNIT 400
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-4267
Practice Address - Country:US
Practice Address - Phone:401-334-1830
Practice Address - Fax:401-334-1833
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN00356364SP0808X
RIAPRN04102363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health