Healthcare Provider Details

I. General information

NPI: 1336496330
Provider Name (Legal Business Name): SUSAN JO PONDER RN, CNS/RXN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 05/31/2021
Certification Date: 05/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 65TH AVE STE 3
GREELEY CO
80634-7965
US

IV. Provider business mailing address

1919 65TH AVENUE, SUITE 3 INTEGRATION MENTAL HEALTH
GREELEY CO
80634
US

V. Phone/Fax

Practice location:
  • Phone: 970-590-1138
  • Fax: 970-356-7437
Mailing address:
  • Phone: 970-590-1138
  • Fax: 970-356-7437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number130627
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: