MEDICARE: SUZANNE KAY FORSYTHE NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R069132-5	MN
2	363LF0000X	Family Nurse Practitioner	R14864	ND

General Provider Information

NPI Number	:	1811917594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE KAY FORSYTHE NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	43150 SHENANDOAH LOOP
Second Line	:
City	:	DENT
State	:	MN
Zip	:	56528-9046
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1821 N PARK ST
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-1247
Country	:	US
Telephone Number	:	218-739-1400
Fax Number	:	218-739-1401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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