Provider Demographics
NPI:1679876379
Name:GODFREY, SUSAN MARIE (ANP-BC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:GODFREY
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-5328
Mailing Address - Country:US
Mailing Address - Phone:781-848-1950
Mailing Address - Fax:781-356-4887
Practice Address - Street 1:759 GRANITE ST
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-5328
Practice Address - Country:US
Practice Address - Phone:781-848-1950
Practice Address - Fax:781-356-4887
Is Sole Proprietor?:No
Enumeration Date:2010-12-19
Last Update Date:2010-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN278087363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner