Provider Demographics
NPI:1124330014
Name:PETERSON, SUSAN GRIZZARD (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:GRIZZARD
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:N
Other - Last Name:GRIZZARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:225 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3050
Practice Address - Country:US
Practice Address - Phone:864-560-4420
Practice Address - Fax:864-560-5296
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC4281363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA57905019OtherMEDICARE PIN
SCNP1650Medicaid
NC7004655Medicaid
SCP01322006OtherRAILROAD MEDICARE
NC7004655Medicaid