Provider Demographics
NPI:1629083506
Name:BODURTHA, SUSAN E (RN, CNS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BODURTHA
Suffix:
Gender:F
Credentials:RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:T-9 FORT MISSOULA
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7202
Mailing Address - Country:US
Mailing Address - Phone:406-532-8400
Mailing Address - Fax:
Practice Address - Street 1:410 WINDWARD WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2680
Practice Address - Country:US
Practice Address - Phone:406-257-1336
Practice Address - Fax:406-257-1353
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN12218364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTS73233Medicare UPIN