Provider Demographics
NPI:1134512072
Name:GILLISPIE, SUSAN MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:GILLISPIE
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 1:7272 THEODORE DAWES RD STE B
Mailing Address - Street 2:
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-4136
Mailing Address - Country:US
Mailing Address - Phone:251-607-6653
Mailing Address - Fax:
Practice Address - Street 1:3838 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2224
Practice Address - Country:US
Practice Address - Phone:503-992-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201240084RN363L00000X
OR201501505NP-PP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner