Provider Demographics
NPI:1336496330
Name:PONDER, SUSAN JO (RN, CNS/RXN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JO
Last Name:PONDER
Suffix:
Gender:F
Credentials:RN, CNS/RXN
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1919 65TH AVENUE, SUITE 3
Mailing Address - Street 2:INTEGRATION MENTAL HEALTH
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634
Mailing Address - Country:US
Mailing Address - Phone:970-590-1138
Mailing Address - Fax:970-356-7437
Practice Address - Street 1:1919 65TH AVE STE 3
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-7965
Practice Address - Country:US
Practice Address - Phone:970-590-1138
Practice Address - Fax:970-356-7437
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO130627364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1134592256Medicaid
CO1336496330OtherCOMMERCIAL