Provider Demographics
NPI:1215793872
Name:BOSE, SUSANNA (WHNP-BC)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:BOSE
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 W MILLER RD
Mailing Address - Street 2:
Mailing Address - City:TOANO
Mailing Address - State:VA
Mailing Address - Zip Code:23168-9525
Mailing Address - Country:US
Mailing Address - Phone:757-592-3354
Mailing Address - Fax:
Practice Address - Street 1:500 SENTARA CIR STE 105
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5727
Practice Address - Country:US
Practice Address - Phone:757-253-5653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024189574363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health