Provider Demographics
NPI:1699973693
Name:FISHMAN TUDOR, SUSAN ELLEN (DC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELLEN
Last Name:FISHMAN TUDOR
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 SUNNYGLEN DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-7553
Mailing Address - Country:US
Mailing Address - Phone:415-730-6305
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-268-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17539111N00000X
NYY005601111N00000X
CA330605163W00000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No111N00000XChiropractic ProvidersChiropractor
No163W00000XNursing Service ProvidersRegistered Nurse