Healthcare Provider Details

I. General information

NPI: 1427802677
Provider Name (Legal Business Name): SUSAN I NORTHWAY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 E COLUMBIA AVE STE 201
COLVILLE WA
99114-3316
US

IV. Provider business mailing address

165 E HAWTHORNE AVE
COLVILLE WA
99114-2629
US

V. Phone/Fax

Practice location:
  • Phone: 509-685-5000
  • Fax:
Mailing address:
  • Phone: 509-684-4597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00085884
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: