Provider Demographics
NPI:1336161884
Name:REILLY, SUSAN LEE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEE
Last Name:REILLY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BOWERS RD.
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05048-0295
Mailing Address - Country:US
Mailing Address - Phone:802-436-2564
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:5L
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-653-9302
Practice Address - Fax:603-650-0902
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH015400-23-04363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30008606Medicaid
VT1004947Medicaid
NHNP0669Medicare ID - Type Unspecified
NH30008606Medicaid