Healthcare Provider Details

I. General information

NPI: 1285146928
Provider Name (Legal Business Name): SUSAN PUDDY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 NW BEAVER ST
PRINEVILLE OR
97754-1802
US

IV. Provider business mailing address

7752 NW COUNTRY LOOP
PRINEVILLE OR
97754-8137
US

V. Phone/Fax

Practice location:
  • Phone: 541-447-5165
  • Fax:
Mailing address:
  • Phone: 541-447-1947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number200140686RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: