MEDICARE: SUSAN FLANNIGAN RNCNP

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	363LA2200X	Adult Health Nurse Practitioner	R 066120-3	MN

General Provider Information

NPI Number	:	1659354793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN FLANNIGAN RNCNP

Provider Business Mailing Address
First Line	:	25323 PIGEON LOFT RD NE
Second Line	:
City	:	STACY
State	:	MN
Zip	:	55079-3161
Country	:	US
Telephone Number	:	651-462-0231
Fax Number	:

Provider Business Practice Location Address
First Line	:	FAIRVIEW LAKES CHISAGO CLINIC
Second Line	:	11725 STINSON AVE
City	:	CHISAGO CITY
State	:	MN
Zip	:	55013-9540
Country	:	US
Telephone Number	:	651-257-8499
Fax Number	:

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	07/08/2007

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