Healthcare Provider Details

I. General information

NPI: 1205809837
Provider Name (Legal Business Name): SUZANNE L K RIDDLE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 S 600 E
SALT LAKE CITY UT
84102-2708
US

IV. Provider business mailing address

443 S 600 E
SALT LAKE CITY UT
84102-2708
US

V. Phone/Fax

Practice location:
  • Phone: 801-538-2057
  • Fax:
Mailing address:
  • Phone: 801-538-2057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number3090203102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: