Healthcare Provider Details

I. General information

NPI: 1891907580
Provider Name (Legal Business Name): SUZANNE KENT NIEMAN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 CLUB RD STE 160
EUGENE OR
97401-2439
US

IV. Provider business mailing address

PO BOX 70779
SPRINGFIELD OR
97475-0137
US

V. Phone/Fax

Practice location:
  • Phone: 541-345-1722
  • Fax: 541-485-7049
Mailing address:
  • Phone: 541-345-1722
  • Fax: 541-485-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202004996NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number202004904RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: