Healthcare Provider Details

I. General information

NPI: 1366317364
Provider Name (Legal Business Name): SUSAN MARGUERITE OWEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2862 E SHADOWVIEW ST
EAGLE ID
83616-5670
US

IV. Provider business mailing address

2862 E SHADOWVIEW ST
EAGLE ID
83616-5670
US

V. Phone/Fax

Practice location:
  • Phone: 208-801-3728
  • Fax:
Mailing address:
  • Phone: 208-801-3728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5471685
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number72955
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: