Healthcare Provider Details

I. General information

NPI: 1225388176
Provider Name (Legal Business Name): SUSAN G O'BRIEN WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11209 N TATUM BLVD STE 255
PHOENIX AZ
85028-6061
US

IV. Provider business mailing address

5801 POSTAL ROAD PO BOX 81064
BELFAST ME
04915-0064
US

V. Phone/Fax

Practice location:
  • Phone: 602-494-5050
  • Fax: 866-777-2248
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number341302
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209005704
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: