Provider Demographics
NPI:1467472829
Name:SALEM, SUZANNE RAE (NP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:RAE
Last Name:SALEM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 W ECHO LANE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302
Mailing Address - Country:US
Mailing Address - Phone:602-292-4997
Mailing Address - Fax:623-939-4849
Practice Address - Street 1:601 W MINGUS AVE
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326
Practice Address - Country:US
Practice Address - Phone:928-649-3805
Practice Address - Fax:928-649-5843
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN034491363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ433871Medicaid
AZ433871Medicaid
AZZ65079Medicare PIN