Provider Demographics
NPI:1154465193
Name:PELICAN, SUSAN GUMPERT (CNM)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:GUMPERT
Last Name:PELICAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21024 COUNTY ROAD 95
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-9315
Mailing Address - Country:US
Mailing Address - Phone:530-668-7940
Mailing Address - Fax:
Practice Address - Street 1:21024 COUNTY ROAD 95
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-9315
Practice Address - Country:US
Practice Address - Phone:530-713-1131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA850367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW008500Medicaid