Provider Demographics
NPI:1508380478
Name:STAPLES, SUSAN KAY (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:STAPLES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 SEARCY WAY
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7168
Mailing Address - Country:US
Mailing Address - Phone:270-467-7180
Mailing Address - Fax:709-042-8622
Practice Address - Street 1:944 SEARCY WAY
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7168
Practice Address - Country:US
Practice Address - Phone:270-467-7180
Practice Address - Fax:270-904-2862
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000855-C-NP363LF0000X
KY3011683363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100475690Medicaid