Healthcare Provider Details

I. General information

NPI: 1346843182
Provider Name (Legal Business Name): SUSSAN LEE GOLDSWORTHY DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1192 N RANGE RIDER PL
VAIL AZ
85641-1560
US

IV. Provider business mailing address

1192 N RANGE RIDER PL
VAIL AZ
85641-1560
US

V. Phone/Fax

Practice location:
  • Phone: 478-225-7590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number296600
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: