Basic Information
| Provider Information | |||||||||
| NPI: | 1679014732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORNIG | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | KAY | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORTON | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | KAY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 715 HORIZON DR | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815068700 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 480 EAST AGATE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANBY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708872179 | ||||||||
| FaxNumber: | 9708879311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2017 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.