Provider Demographics
NPI:1407836307
Name:SEBALLOZ, SUZANNE MARIE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:SEBALLOZ
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:USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:1650 COCHRANE CIRCLE, ATTN: CREDENTIALS OFFICE
Mailing Address - City:FORT CARSAN
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4604
Mailing Address - Country:US
Mailing Address - Phone:719-526-7844
Mailing Address - Fax:719-526-7984
Practice Address - Street 1:USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:1650 COCHREAN CIRCLE, ATTN: CREDENTIALS OFFICE
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4604
Practice Address - Country:US
Practice Address - Phone:719-526-7844
Practice Address - Fax:719-526-7984
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12853164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse