Provider Demographics
NPI:1629191648
Name:KILLAM, SUSAN MARY (RN,MSN,NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:KILLAM
Suffix:
Gender:F
Credentials:RN,MSN,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1626
Mailing Address - Country:US
Mailing Address - Phone:231-547-5871
Mailing Address - Fax:
Practice Address - Street 1:NORTHWEST MICHIGAN COMMUNITY HEALTH AGENCY
Practice Address - Street 2:220 W. GARFIELD STREET
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720
Practice Address - Country:US
Practice Address - Phone:231-547-6523
Practice Address - Fax:231-547-6238
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704087772363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISK087772OtherBCBSM