Provider Demographics
NPI:1275087116
Name:MOERER, SUSAN VAUGHN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:VAUGHN
Last Name:MOERER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8445 SW WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-1737
Mailing Address - Country:US
Mailing Address - Phone:503-292-6271
Mailing Address - Fax:
Practice Address - Street 1:8445 SW WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-1737
Practice Address - Country:US
Practice Address - Phone:503-292-6271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR076037101N3 ANP-PP163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse