Provider Demographics
NPI:1821035031
Name:SLATTERY, SUSAN B (CNM, WHNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:SLATTERY
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7337
Mailing Address - Country:US
Mailing Address - Phone:541-482-9741
Mailing Address - Fax:541-488-6141
Practice Address - Street 1:99 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1787
Practice Address - Country:US
Practice Address - Phone:541-482-9741
Practice Address - Fax:541-488-6141
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001582367A00000X
WI14663363L00000X
OR200850169NP363LP2300X, 363LW0102X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-001582OtherAPN LICENSE
IL041-305999OtherRN LICENSE
OR200850169NPOtherOREGON LICENSE