Basic Information
| Provider Information | |||||||||
| NPI: | 1184783482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINDHAM | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 701 UNIVERSITY BLVD E | ||||||||
| Address2: | SUITE 908 | ||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354012086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053449393 | ||||||||
| FaxNumber: | 2057597744 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 UNIVERSITY BLVD E | ||||||||
| Address2: | SUITE 908 | ||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354012086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053449393 | ||||||||
| FaxNumber: | 2057597744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 12/20/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1043954 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 510I500294 | 01 | AL | MEDICARE | OTHER | 051040513 | 01 | AL | BCBS OF ALABAMA | OTHER | 103896 | 05 | AL | MEDICAID |