Provider Demographics
NPI:1285627646
Name:KAZMIERSKI, SUSAN H (CFNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:H
Last Name:KAZMIERSKI
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:538 N. PASEO DE ONATE
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:3396 STATE ROAD 96,
Practice Address - Street 2:
Practice Address - City:COYOTE
Practice Address - State:NM
Practice Address - Zip Code:87012-0040
Practice Address - Country:US
Practice Address - Phone:575-638-5487
Practice Address - Fax:575-638-9123
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR26380363LF0000X
NMCNP00503363LF0000X
NM422367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM92197Medicaid
NMNM400323OtherMEDICARE PTAN
NMNM400323OtherMEDICARE PTAN