Provider Demographics
NPI:1508820473
Name:HOLTKAMP, SUSAN J (CPNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:HOLTKAMP
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:WEINRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:5409 AVENUE O
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-9601
Mailing Address - Country:US
Mailing Address - Phone:319-376-2134
Mailing Address - Fax:319-376-2188
Practice Address - Street 1:5409 AVENUE O
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9601
Practice Address - Country:US
Practice Address - Phone:319-376-2134
Practice Address - Fax:319-376-2188
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC134848363LP0200X, 364SP0200X
MO146525363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO185413OtherBLUE CHOICE
P00805205OtherRAILROAD MEDICARE
MO185413OtherBLUE SHIELD
MO739476OtherHEALTHLINK
MO431560263OtherTRICARE WEST
IA1558340968Medicaid
MOP85288Medicare UPIN
AR181320758Medicaid
MO815195236Medicare PIN
P00805205OtherRAILROAD MEDICARE
MO427848106Medicaid
MO431560263OtherTRICARE WEST