Basic Information
| Provider Information | |||||||||
| NPI: | 1376734418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1542 GOLF COURSE RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557443555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183277973 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 08/05/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R145662-4 | MN | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 364T2AN | 01 | MN | BCBS | OTHER |