Healthcare Provider Details

I. General information

NPI: 1235409764
Provider Name (Legal Business Name): SUSAN GAY COLLINS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 5TH AVE NW
MINOT ND
58703-1902
US

IV. Provider business mailing address

1503 5TH AVE NW
MINOT ND
58703-1902
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-7401
  • Fax: 701-774-7479
Mailing address:
  • Phone: 701-774-7401
  • Fax: 701-774-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR31176
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR31176
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: