Provider Demographics
NPI:1962406959
Name:CASELLI, SUSAN (CFNP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:CASELLI
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 SAGO ROAD RT. 1
Mailing Address - Street 2:BOX 74N
Mailing Address - City:ANGUILLA
Mailing Address - State:MS
Mailing Address - Zip Code:38721
Mailing Address - Country:US
Mailing Address - Phone:662-873-4666
Mailing Address - Fax:
Practice Address - Street 1:25 S FOURTH ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5146
Practice Address - Country:US
Practice Address - Phone:662-873-0477
Practice Address - Fax:662-873-0742
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR604569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122933Medicaid
MS00122933Medicaid
P73053Medicare UPIN