Provider Demographics
NPI:1629334651
Name:RALPH, SUSAN L (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:RALPH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LYNETTE
Other - Last Name:LORDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4914 ASBURY WAY
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-7908
Mailing Address - Country:US
Mailing Address - Phone:208-695-3587
Mailing Address - Fax:
Practice Address - Street 1:14 S BALTIC PL
Practice Address - Street 2:SUITE 106
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5935
Practice Address - Country:US
Practice Address - Phone:208-887-4872
Practice Address - Fax:208-887-6331
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-45447363LF0000X
AZTAP4415363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily