Healthcare Provider Details

I. General information

NPI: 1518013705
Provider Name (Legal Business Name): SUSAN WRONA PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2007
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 COTTAGE ST
MEDFORD OR
97504-7332
US

IV. Provider business mailing address

14 COTTAGE ST
MEDFORD OR
97504-7332
US

V. Phone/Fax

Practice location:
  • Phone: 541-292-6722
  • Fax: 541-326-0028
Mailing address:
  • Phone: 541-292-6722
  • Fax: 541-326-0028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number000033109N6 PMHNP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: