Provider Demographics
NPI:1659446433
Name:SIMON, SUSAN LYNNE (CNM)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNNE
Last Name:SIMON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 PAN AMERICAN EAST FWY NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3427
Mailing Address - Country:US
Mailing Address - Phone:505-727-6200
Mailing Address - Fax:505-727-9590
Practice Address - Street 1:4705 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1226
Practice Address - Country:US
Practice Address - Phone:505-727-4500
Practice Address - Fax:505-727-4505
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR25073176B00000X
NM441176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Z9909Medicaid
AZ761769Medicaid
AZS87625Medicare UPIN
NM329293YT41Medicare PIN