Healthcare Provider Details

I. General information

NPI: 1346216975
Provider Name (Legal Business Name): SUSAN LYNN BUNNELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 E 25TH STREET
IDAHO FALLS ID
83404
US

IV. Provider business mailing address

2280 E 25TH STREET
IDAHO FALLS ID
83404
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-2295
  • Fax: 208-227-2364
Mailing address:
  • Phone: 208-227-2295
  • Fax: 208-227-2364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5576
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberM11154
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: