Provider Demographics
NPI:1699804351
Name:FITZGERALD, SUZAN MARIE
Entity type:Individual
Prefix:
First Name:SUZAN
Middle Name:MARIE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8541 E VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-8977
Mailing Address - Country:US
Mailing Address - Phone:907-321-9949
Mailing Address - Fax:888-649-1758
Practice Address - Street 1:8541 E VALLEY CT
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-8977
Practice Address - Country:US
Practice Address - Phone:907-321-9949
Practice Address - Fax:888-649-1758
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCMG54911171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG54911Medicaid