Provider Demographics
NPI:1285778761
Name:RICHARDSON, SUSANA M (NP)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:M
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3106 STONEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2183
Mailing Address - Country:US
Mailing Address - Phone:805-522-2603
Mailing Address - Fax:
Practice Address - Street 1:7515 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-1949
Practice Address - Country:US
Practice Address - Phone:818-947-4026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13367363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health