Provider Demographics
NPI:1376041426
Name:WALDEN, SUSAN J (FNP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:WALDEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 WAPIYAPI AVE
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:SD
Mailing Address - Zip Code:57752-3115
Mailing Address - Country:US
Mailing Address - Phone:605-455-2451
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:1000 HEALTH CENTER ROAD
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:SD
Practice Address - Zip Code:57752
Practice Address - Country:US
Practice Address - Phone:605-455-2451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN256011363L00000X, 163W00000X, 163WC0400X
SDCP002059363L00000X
GARN256001363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management