Provider Demographics
NPI:1467445486
Name:KENT, SUSAN MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:KENT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2205
Mailing Address - Country:US
Mailing Address - Phone:651-696-9110
Mailing Address - Fax:651-696-9119
Practice Address - Street 1:1418 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2205
Practice Address - Country:US
Practice Address - Phone:651-696-9110
Practice Address - Fax:651-696-9119
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2722111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN273528800Medicaid