Provider Demographics
NPI:1558480756
Name:NICHOLSON, SUSAN SANGER (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:SANGER
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 MOUNTAIN VIEW AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3178
Mailing Address - Country:US
Mailing Address - Phone:303-702-5910
Mailing Address - Fax:303-702-5935
Practice Address - Street 1:2030 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3182
Practice Address - Country:US
Practice Address - Phone:303-702-5910
Practice Address - Fax:303-702-5935
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03039277Medicaid