Provider Demographics
NPI:1518971217
Name:TIPTON, SUSAN KATHLEEN (RN NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KATHLEEN
Last Name:TIPTON
Suffix:
Gender:F
Credentials:RN NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:KATHLEEN
Other - Last Name:TIPTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1524 MCHENRY AVE
Mailing Address - Street 2:SUITE 445
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4500
Mailing Address - Country:US
Mailing Address - Phone:209-548-0114
Mailing Address - Fax:209-571-0326
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 445
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-571-1693
Practice Address - Fax:209-571-0326
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14915363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14915OtherNP
CA308602OtherRN