Healthcare Provider Details

I. General information

NPI: 1265739742
Provider Name (Legal Business Name): SUSAN LARA ALBRIGHT ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 UNION AVE
GRANTS PASS OR
97527-5543
US

IV. Provider business mailing address

2825 E BARNETT RD OFC
MEDFORD OR
97504-8332
US

V. Phone/Fax

Practice location:
  • Phone: 541-507-2170
  • Fax:
Mailing address:
  • Phone: 541-789-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.12204-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201501648NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: