Healthcare Provider Details

I. General information

NPI: 1689593014
Provider Name (Legal Business Name): SUSAN BALLENTINE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 INTERSTATE 45 N STE 100
CONROE TX
77304-2185
US

IV. Provider business mailing address

3251 INTERSTATE 45 N STE 100
CONROE TX
77304-2185
US

V. Phone/Fax

Practice location:
  • Phone: 936-520-9604
  • Fax:
Mailing address:
  • Phone: 936-520-9604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number823561
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: