Healthcare Provider Details

I. General information

NPI: 1265527121
Provider Name (Legal Business Name): SUSAN CHIYO MARTIN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 S KIPLING ST
LAKEWOOD CO
80226-1086
US

IV. Provider business mailing address

9362 DESERT WILLOW WAY
HIGHLANDS RANCH CO
80129-5743
US

V. Phone/Fax

Practice location:
  • Phone: 303-239-7171
  • Fax:
Mailing address:
  • Phone: 303-791-9607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number58569
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: