Healthcare Provider Details

I. General information

NPI: 1336360254
Provider Name (Legal Business Name): SUSAN DIANE OTT HEASLEY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N MAIN ST
CHENEY KS
67025-8844
US

IV. Provider business mailing address

2101 N WALDRON ST
HUTCHINSON KS
67502-1197
US

V. Phone/Fax

Practice location:
  • Phone: 620-259-6221
  • Fax: 316-540-6193
Mailing address:
  • Phone: 620-669-2500
  • Fax: 316-540-6193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011020340
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6554
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05-45046
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: