Provider Demographics
NPI:1477543759
Name:RAVESSOUD, SUSANN (NP)
Entity Type:Individual
Prefix:
First Name:SUSANN
Middle Name:
Last Name:RAVESSOUD
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:PO BOX 221530
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-4530
Mailing Address - Country:US
Mailing Address - Phone:915-598-7246
Mailing Address - Fax:
Practice Address - Street 1:3500 NORTHRISE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7274
Practice Address - Country:US
Practice Address - Phone:575-395-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN430276163W00000X
NMRN-74298163W00000X
CANP10007363L00000X
NMCNP-01878363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00453277Medicaid
NM00453277Medicaid