Provider Demographics
NPI:1154533875
Name:KIRBY, SUSAN H (NP-C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:H
Last Name:KIRBY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2041 MESA VALLEY WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6828
Mailing Address - Country:US
Mailing Address - Phone:770-944-1100
Mailing Address - Fax:770-944-6469
Practice Address - Street 1:2041 MESA VALLEY WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6828
Practice Address - Country:US
Practice Address - Phone:770-944-1100
Practice Address - Fax:770-944-6469
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF0207056363L00000X
GARN157966363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA475644168AMedicaid
GA475644168BMedicaid
GA475644168CMedicaid
GA511I500135Medicare PIN