Provider Demographics
NPI:1427078153
Name:DELISLE, SUSAN MARTA (ANP, PMHNP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARTA
Last Name:DELISLE
Suffix:
Gender:F
Credentials:ANP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 W 168TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-4103
Mailing Address - Country:US
Mailing Address - Phone:122-326-5705
Mailing Address - Fax:
Practice Address - Street 1:516 W 168TH ST FL 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-4103
Practice Address - Country:US
Practice Address - Phone:122-326-5705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304323-1363LA2200X
NY402436363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health