Basic Information
Provider Information | |||||||||
NPI: | 1689882573 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MARKLEY | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2500 ROCKY MOUNTAIN AVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | LOVELAND | ||||||||
State: | CO | ||||||||
PostalCode: | 805389004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706241800 | ||||||||
FaxNumber: | 9706241891 | ||||||||
Practice Location | |||||||||
Address1: | 2500 ROCKY MOUNTAIN AVE | ||||||||
Address2: | STE 100 | ||||||||
City: | LOVELAND | ||||||||
State: | CO | ||||||||
PostalCode: | 805389004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706241800 | ||||||||
FaxNumber: | 9706241891 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2007 | ||||||||
LastUpdateDate: | 06/12/2014 | ||||||||
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 | 163W00000X | 77001 | CO | N |   | Nursing Service Providers | Registered Nurse |   | 363L00000X | 5118 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 96432888 | 05 | CO |   | MEDICAID |