Provider Demographics
NPI:1912018474
Name:HIBBS, SUSAN MILEY (CFNP, RN, CDE)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MILEY
Last Name:HIBBS
Suffix:
Gender:F
Credentials:CFNP, RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1213 E FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2923
Mailing Address - Country:US
Mailing Address - Phone:612-872-8086
Mailing Address - Fax:612-872-8547
Practice Address - Street 1:1213 E FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2923
Practice Address - Country:US
Practice Address - Phone:612-872-8086
Practice Address - Fax:612-872-8547
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR1079194363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR1079194Medicaid
MNR1079194Medicaid