Provider Demographics
NPI:1003816232
Name:AHN, SUSIE KIM (FNP)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:KIM
Last Name:AHN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 570492
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75357-0492
Mailing Address - Country:US
Mailing Address - Phone:562-714-8609
Mailing Address - Fax:206-202-3378
Practice Address - Street 1:1105 CENTRAL EXPY N STE 2240
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6114
Practice Address - Country:US
Practice Address - Phone:866-607-2308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX712630363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173668801Medicaid
TXQ04732Medicare UPIN