Healthcare Provider Details

I. General information

NPI: 1487645297
Provider Name (Legal Business Name): SUSAN L DONOHUE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 LAKE OTIS PKWY SUITE 202
ANCHORAGE AK
99508-5215
US

IV. Provider business mailing address

PO BOX 521404 3070 SOUTH HORSESHOE LAKE ROAD
BIG LAKE AK
99652-1404
US

V. Phone/Fax

Practice location:
  • Phone: 907-338-2273
  • Fax: 907-338-2284
Mailing address:
  • Phone: 907-892-6602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2707-0035
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: