MEDICARE: SUSAN RAE EARLY RN

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	163WS0200X	School Registered Nurse	R36016	NM

General Provider Information

NPI Number	:	1992215891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN RAE EARLY RN

Provider Business Mailing Address
First Line	:	PO BOX 2000
Second Line	:
City	:	MORIARTY
State	:	NM
Zip	:	87035-2000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2422 EAST HWY 333
Second Line	:
City	:	MORIARTY
State	:	NM
Zip	:	87035
Country	:	US
Telephone Number	:	505-832-6827
Fax Number	:

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

Provider Enumeration Date	:	10/05/2017
Last Update Date	:	10/05/2017

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