Healthcare Provider Details

I. General information

NPI: 1902877590
Provider Name (Legal Business Name): SUSAN BLIGH ROBERTSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5658 HIGHWAY 260 SUITE 24
LAKESIDE AZ
85929-5189
US

IV. Provider business mailing address

5423 BLACK BEAR WAY
LAKESIDE AZ
85929-5514
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-4379
  • Fax: 928-537-4653
Mailing address:
  • Phone: 928-368-5493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM8247106
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: