Provider Demographics
NPI:1578385498
Name:AVEDISSIAN, SUSAN J
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:AVEDISSIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MILL ST APT 2301
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-1727
Mailing Address - Country:US
Mailing Address - Phone:508-509-7349
Mailing Address - Fax:
Practice Address - Street 1:80 MILL ST APT 2301
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-1727
Practice Address - Country:US
Practice Address - Phone:508-509-7349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-305651163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant