Provider Demographics
NPI:1073540605
Name:DUMMER, SUSAN L (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:DUMMER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 W. IRONWOOD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-765-1455
Mailing Address - Fax:208-667-8655
Practice Address - Street 1:980 W. IRONWOOD
Practice Address - Street 2:SUITE 101
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-765-1455
Practice Address - Fax:208-667-8655
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP203A363L00000X
IDN-19918363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002791900Medicaid
ID1341531Medicare ID - Type Unspecified
ID002791900Medicaid