Healthcare Provider Details

I. General information

NPI: 1477529600
Provider Name (Legal Business Name): SUSAN MARGARET BACHELLER CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 24TH AVE STE 204
FORT GRATIOT MI
48059-3884
US

IV. Provider business mailing address

4190 24TH AVE STE 204
FORT GRATIOT MI
48059-3884
US

V. Phone/Fax

Practice location:
  • Phone: 810-216-1000
  • Fax: 810-216-3138
Mailing address:
  • Phone: 810-216-1000
  • Fax: 810-216-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704136802
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: