=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346216975
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN LYNN BUNNELL MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2006
-----------------------------------------------------
Last Update Date | 12/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2280 E 25TH STREET
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-227-2295
-----------------------------------------------------
Fax | 208-227-2364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2280 E 25TH STREET
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-227-2295
-----------------------------------------------------
Fax | 208-227-2364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 5576
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | M11154
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------