Healthcare Provider Details

I. General information

NPI: 1336553601
Provider Name (Legal Business Name): SUE ANN HIGINBOTHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13140 W EL LOBO RD
TUCSON AZ
85743-9390
US

IV. Provider business mailing address

13140 W EL LOBO RD
TUCSON AZ
85743-9390
US

V. Phone/Fax

Practice location:
  • Phone: 608-395-9653
  • Fax:
Mailing address:
  • Phone: 608-395-9653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberTRN185728
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number174788-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: