Healthcare Provider Details

I. General information

NPI: 1356384317
Provider Name (Legal Business Name): SUSAN F BAKER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

IHS MAIN STREET
EAGLE BUTTE SD
57625-1012
US

IV. Provider business mailing address

PO BOX 1145
EAGLE BUTTE SD
57625-1145
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-3004
  • Fax: 605-964-1110
Mailing address:
  • Phone: 605-964-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR025934
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: