Provider Demographics
NPI:1205140043
Name:ROTHBERG, SUZANNE O'ROURKE (WHNP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:O'ROURKE
Last Name:ROTHBERG
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 E 200 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2503
Mailing Address - Country:US
Mailing Address - Phone:218-230-4108
Mailing Address - Fax:
Practice Address - Street 1:1906 W 3600 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-4715
Practice Address - Country:US
Practice Address - Phone:801-973-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6592021-4408363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health