MEDICARE: MS. SUSAN CONSTANCE RN

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	163WP2201X	Ambulatory Care Registered Nurse	126420	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HSZ196	OTHER	NM	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467476440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN CONSTANCE RN

Provider Business Mailing Address
First Line	:	PO BOX 269
Second Line	:
City	:	DULCE
State	:	NM
Zip	:	87528-0269
Country	:	US
Telephone Number	:	505-759-1691
Fax Number	:	505-759-7294

Provider Business Practice Location Address
First Line	:	500 NORTH MUNDO
Second Line	:
City	:	DULCE
State	:	NM
Zip	:	87528-0269
Country	:	US
Telephone Number	:	505-759-3291
Fax Number	:	505-759-7294

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	09/20/2010

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