Provider Demographics
NPI:1659354793
Name:FLANNIGAN, SUSAN (RNCNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FLANNIGAN
Suffix:
Gender:F
Credentials:RNCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25323 PIGEON LOFT RD NE
Mailing Address - Street 2:
Mailing Address - City:STACY
Mailing Address - State:MN
Mailing Address - Zip Code:55079-3161
Mailing Address - Country:US
Mailing Address - Phone:651-462-0231
Mailing Address - Fax:
Practice Address - Street 1:FAIRVIEW LAKES CHISAGO CLINIC
Practice Address - Street 2:11725 STINSON AVE
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9540
Practice Address - Country:US
Practice Address - Phone:651-257-8499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 066120-3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN573694Medicare UPIN