Provider Demographics
NPI:1558309211
Name:BAKKEN, SUZANNE LEA (NP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LEA
Last Name:BAKKEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:LEA
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1201 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-0400
Mailing Address - Country:US
Mailing Address - Phone:605-328-7090
Mailing Address - Fax:605-328-7091
Practice Address - Street 1:1201 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-7700
Practice Address - Country:US
Practice Address - Phone:605-328-7090
Practice Address - Fax:605-328-7091
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR030642363L00000X
SDCP000417363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS101564Medicare PIN