Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 26NJ01244400 | NJ |
NPI | 1003571621 |
---|---|
Provider Name | Susanna Im |
First Address | Voorhees, NJ 08043-1661 |
Second Address | Washington Township, NJ 08080 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2021 |
Last Update Date | 06/01/2022 |