Healthcare Provider Details

I. General information

NPI: 1407421738
Provider Name (Legal Business Name): SUSAN LUCY NINHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/20/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24760 HOSPITAL DR NW
REDLAKE MN
56671-0249
US

IV. Provider business mailing address

PO BOX 249
REDLAKE MN
56671-0249
US

V. Phone/Fax

Practice location:
  • Phone: 218-679-0118
  • Fax:
Mailing address:
  • Phone: 218-679-0118
  • Fax: 218-679-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: