Provider Demographics
NPI:1013936541
Name:STUTZMAN, SUSAN P (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:STUTZMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:P
Other - Last Name:STUTZMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:215 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1912
Mailing Address - Country:US
Mailing Address - Phone:208-799-3100
Mailing Address - Fax:208-799-0349
Practice Address - Street 1:215 10TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1912
Practice Address - Country:US
Practice Address - Phone:208-799-3100
Practice Address - Fax:208-799-0349
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP198A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9604349Medicaid
WA9604349Medicaid