Basic Information
| Provider Information | |||||||||
| NPI: | 1053648113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | SAMPLES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HILLIS | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | SAMPLES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2409 HOMER CLAYTON DR | ||||||||
| Address2: | |||||||||
| City: | GUNTERSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359762207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565823203 | ||||||||
| FaxNumber: | 2565823216 | ||||||||
| Practice Location | |||||||||
| Address1: | 4884 AL HIGHWAY 40 | ||||||||
| Address2: | |||||||||
| City: | DUTTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357447330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562286514 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2009 | ||||||||
| LastUpdateDate: | 11/11/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1-066210 | AL | Y | Nursing Service Providers | Registered Nurse | 163WA0400X | 1-066210 | AL | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WP0808X | 1-066210 | AL | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 163WP0809X | 1-066210 | AL | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.