Healthcare Provider Details

I. General information

NPI: 1841304508
Provider Name (Legal Business Name): SUSAN VAN NORDHEIM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN HUDSON ABBOTT NP

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DRIVE
LA MESA CA
91942
US

IV. Provider business mailing address

5555 GROSSMONT CENTER DRIVE
LA MESA CA
91942
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-6000
  • Fax: 619-740-4213
Mailing address:
  • Phone: 619-740-6000
  • Fax: 619-740-4213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP13296
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP13296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: