Provider Demographics
NPI:1205823077
Name:NYLEN, SUSAN (NFP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NYLEN
Suffix:
Gender:F
Credentials:NFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 NORMAN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-5900
Mailing Address - Country:US
Mailing Address - Phone:209-825-7748
Mailing Address - Fax:
Practice Address - Street 1:1140 NORMAN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5900
Practice Address - Country:US
Practice Address - Phone:209-825-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA23049Medicare UPIN
CAZZZ26112ZMedicare ID - Type Unspecified