Healthcare Provider Details

I. General information

NPI: 1790777100
Provider Name (Legal Business Name): SUSAN RAE AULT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 EAST ST
ANDERSON CA
96007-3408
US

IV. Provider business mailing address

2830 EAST ST
ANDERSON CA
96007-3408
US

V. Phone/Fax

Practice location:
  • Phone: 530-365-2545
  • Fax: 530-365-3871
Mailing address:
  • Phone: 530-365-2545
  • Fax: 530-365-3871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200450018NP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14768
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code364SX0200X
TaxonomyOncology Clinical Nurse Specialist
License Number200570025CNS
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number083045668RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: