Provider Demographics
NPI:1710582143
Name:BOEHM, SUSAN MAE
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MAE
Last Name:BOEHM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E TURNPIKE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1760
Mailing Address - Country:US
Mailing Address - Phone:701-220-0807
Mailing Address - Fax:
Practice Address - Street 1:116 E TURNPIKE AVE APT 1
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1760
Practice Address - Country:US
Practice Address - Phone:701-220-0807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant