Healthcare Provider Details

I. General information

NPI: 1407178957
Provider Name (Legal Business Name): SUE LILLIAN DEVERS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUE LILLIAN SLEMMER

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3449 E REZANOF DR
KODIAK AK
99615
US

IV. Provider business mailing address

3449 E REZANOF DR
KODIAK AK
99615
US

V. Phone/Fax

Practice location:
  • Phone: 907-486-9870
  • Fax: 907-486-9897
Mailing address:
  • Phone: 907-486-9870
  • Fax: 907-486-9897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4497
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4497
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: