Basic Information
| Provider Information | |||||||||
| NPI: | 1912358730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTELL | ||||||||
| FirstName: | SUSANNAH | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3896 BEVERLY AVE NE | ||||||||
| Address2: | BLDG J, SUITE 40 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035880076 | ||||||||
| FaxNumber: | 5035880531 | ||||||||
| Practice Location | |||||||||
| Address1: | 3896 BEVERLY AVE NE | ||||||||
| Address2: | BLDG J, SUITE 40 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035880076 | ||||||||
| FaxNumber: | 5035880531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2016 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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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 | 363LF0000X | 201606933NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 099000190RN | OR | N | Nursing Service Providers | Registered Nurse |
No ID Information.