Healthcare Provider Details

I. General information

NPI: 1518971217
Provider Name (Legal Business Name): SUSAN KATHLEEN TIPTON RN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN KATHLEEN TIPTON RN

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE SUITE 445
MODESTO CA
95350-4500
US

IV. Provider business mailing address

1524 MCHENRY AVE SUITE 445
MODESTO CA
95350-4500
US

V. Phone/Fax

Practice location:
  • Phone: 209-571-1693
  • Fax: 209-571-0326
Mailing address:
  • Phone: 209-548-0114
  • Fax: 209-571-0326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14915
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: