Individual
SUSADA INTHAVONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
1504 SULLIVAN AVE, SOUTH WINDSOR, CT 06074-2711
(860) 644-1523
(860) 648-9468
Mailing address
29 NAEK RD, SUITE 5, VERNON, CT 06066-3942
(860) 872-2289
(860) 896-1425
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
003968
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003968
STATE LICENSE
CT
Enumeration date
01/12/2009
Last updated
01/12/2009
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