Provider Demographics
NPI:1508824699
Name:WATERBURY, SUSAN RUTH (NP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:RUTH
Last Name:WATERBURY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 560135
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-0135
Mailing Address - Country:US
Mailing Address - Phone:321-291-3589
Mailing Address - Fax:
Practice Address - Street 1:3000 MURRELL RD, UNIT 560135
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32956-0135
Practice Address - Country:US
Practice Address - Phone:321-291-3589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL314100168363L00000X
VA0001251055363LF0000X
FLAPRN2116242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303783500Medicaid
FLY0023AMedicare ID - Type Unspecified
FL303783500Medicaid