Provider Demographics
NPI:1790777100
Name:AULT, SUSAN RAE (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RAE
Last Name:AULT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 EAST ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007-3408
Mailing Address - Country:US
Mailing Address - Phone:530-365-2545
Mailing Address - Fax:530-365-3871
Practice Address - Street 1:2830 EAST ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-3408
Practice Address - Country:US
Practice Address - Phone:530-365-2545
Practice Address - Fax:530-365-3871
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR083045668RN163WG0000X
OR200450018NP363L00000X
OR200570025CNS364SX0200X
CA14768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278215Medicaid
OR1407812365OtherGROUP NPI NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR930635514OtherGROUP TAX ID NUMBER
OR278215Medicaid
OR1407812365OtherGROUP NPI NUMBER
OR0577260001Medicare NSC