Provider Demographics
NPI:1407865033
Name:BAUER, SUSAN M (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:BAUER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:MEHLENBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:205 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6521
Practice Address - Country:US
Practice Address - Phone:573-884-6052
Practice Address - Fax:573-884-1151
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO063861363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425295409Medicaid
MO455963OtherHEALTHLINK