Provider Demographics
NPI:1023015104
Name:BLANCHARD, SUZANNE A (NP)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:A
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 SHORT DRIVE
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-0019
Mailing Address - Country:US
Mailing Address - Phone:989-366-1515
Mailing Address - Fax:
Practice Address - Street 1:1401 SHORT DRIVE
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-0019
Practice Address - Country:US
Practice Address - Phone:989-366-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704203066363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4577440 TYPE 10Medicaid
MI5008702190OtherBLUE CROSS BLUE SHIELD
MIMB016102OtherDEA
MAON83500Medicare ID - Type UnspecifiedMEDICARE GROUP
MIMB016102OtherDEA
MIP43636Medicare UPIN