Provider Demographics
NPI:1306956784
Name:GERACE, SUSAN JANE (NP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JANE
Last Name:GERACE
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 1:4220 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5101
Mailing Address - Country:US
Mailing Address - Phone:602-279-7655
Mailing Address - Fax:602-253-8891
Practice Address - Street 1:1930 S ALMA SCHOOL RD
Practice Address - Street 2:STE. A104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3064
Practice Address - Country:US
Practice Address - Phone:483-820-0825
Practice Address - Fax:480-820-7863
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN038613363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105328Medicare ID - Type Unspecified
AZP49116Medicare UPIN