Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist | RBT-21-167101 | NC |
NPI | 1174293583 |
---|---|
Provider Name | Callista M Susen |
First Address | Fayetteville, NC 28304-3186 |
Second Address | Fayetteville, NC 28304-3186 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2021 |
Last Update Date | 16/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
09162021 | (05) | FL |