Provider Demographics
NPI:1487743464
Name:FAVORITE, SUSAN BRIDGET (CRNA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BRIDGET
Last Name:FAVORITE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-2024
Mailing Address - Country:US
Mailing Address - Phone:717-627-4431
Mailing Address - Fax:
Practice Address - Street 1:169 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1724
Practice Address - Country:US
Practice Address - Phone:717-738-6618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA071093367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN302905LOtherRN LICENSE