Healthcare Provider Details

I. General information

NPI: 1063565281
Provider Name (Legal Business Name): SUSAN CAROL NOKLEBY RN, MS, LSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GILLETT DR NW
BEMIDJI MN
56601-5668
US

IV. Provider business mailing address

912 DONALD AVE SE
BEMIDJI MN
56601-4904
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-3100
  • Fax: 218-333-3175
Mailing address:
  • Phone: 218-751-3353
  • Fax: 218-333-3175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR 075546-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: