MEDICARE: SUSAN LUCY NINHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker		MN

General Provider Information

NPI Number	:	1407421738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN LUCY NINHAM

Provider Business Mailing Address
First Line	:	PO BOX 249
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0249
Country	:	US
Telephone Number	:	218-679-0118
Fax Number	:	218-679-3990

Provider Business Practice Location Address
First Line	:	24760 HOSPITAL DR NW
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0249
Country	:	US
Telephone Number	:	218-679-0118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2021
Last Update Date	:	05/20/2021

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