Provider Demographics
NPI:1407421738
Name:NINHAM, SUSAN LUCY
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LUCY
Last Name:NINHAM
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:REDLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-0249
Mailing Address - Country:US
Mailing Address - Phone:218-679-0118
Mailing Address - Fax:218-679-3990
Practice Address - Street 1:24760 HOSPITAL DR NW
Practice Address - Street 2:
Practice Address - City:REDLAKE
Practice Address - State:MN
Practice Address - Zip Code:56671-0249
Practice Address - Country:US
Practice Address - Phone:218-679-0118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty