Healthcare Provider Details

I. General information

NPI: 1184604860
Provider Name (Legal Business Name): SUSAN HERROLD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 N SARATOGA ST COMMAND SUITE
OAK HARBOR WA
98278-4927
US

IV. Provider business mailing address

1307 BAKER CT
OAK HARBOR WA
98277-3336
US

V. Phone/Fax

Practice location:
  • Phone: 360-257-9974
  • Fax:
Mailing address:
  • Phone: 360-240-1883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN094915
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: