Provider Demographics
NPI:1336364728
Name:NURSE PRACTITIONER GUILD, INC
Entity Type:Organization
Organization Name:NURSE PRACTITIONER GUILD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:SALEM
Authorized Official - Suffix:
Authorized Official - Credentials:N P
Authorized Official - Phone:928-649-3805
Mailing Address - Street 1:PO BOX 3125
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-2590
Mailing Address - Country:US
Mailing Address - Phone:928-649-3805
Mailing Address - Fax:
Practice Address - Street 1:601 W MINGUS AVE
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4075
Practice Address - Country:US
Practice Address - Phone:928-649-3805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN034491363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ65079Medicare PIN