Provider Demographics
NPI:1558309328
Name:VAN FOSSEN, SUSAN J (RN, MSN, BC, PMHNP,)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:J
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:RN, MSN, BC, PMHNP,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 CLIFF SWALLOW DR
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-2651
Mailing Address - Country:US
Mailing Address - Phone:817-579-6757
Mailing Address - Fax:800-819-1655
Practice Address - Street 1:616 W RUSSELL PL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3658
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX232874363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87N290OtherBLUE CROSS BLUE SHIELD
TX118282603Medicaid
TX118282605OtherINDIVIDUAL
TX118282601Medicaid
TX500012787OtherRAILROAD
TX118282602Medicaid
TX8N3327OtherBLUE CROSS BLUE SHIELD
TX85N013Medicare ID - Type Unspecified
TX118282602Medicaid
TX118282601Medicaid