Provider Demographics
NPI:1164628442
Name:EDELMAN, SUZANNE KEELE (ANP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:KEELE
Last Name:EDELMAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4008
Mailing Address - Country:US
Mailing Address - Phone:208-554-2006
Mailing Address - Fax:
Practice Address - Street 1:4702 W CHERRY CREEK ROAD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:ID
Practice Address - Zip Code:83255
Practice Address - Country:US
Practice Address - Phone:208-554-2006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-325A363LC1500X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Not Answered363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNP-325AOtherANP LICENSE
IDN-10732OtherRN LICENSE
IDME1563990OtherCONTROLLED SUBSTANCE REG.