Provider Demographics
NPI:1356366405
Name:GUTIERREZ, SUSAN M (FNP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MERCY WAY
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4524
Mailing Address - Country:US
Mailing Address - Phone:417-556-2300
Mailing Address - Fax:417-556-2906
Practice Address - Street 1:100 MERCY WAY
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4524
Practice Address - Country:US
Practice Address - Phone:417-556-2300
Practice Address - Fax:417-556-2906
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO125666363LC0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO185426OtherBCBS
OK200022690AMedicaid
KS200253250DMedicaid
MOP01080619OtherRAIL ROAD MEDICARE
MO428980205Medicaid
KS200253250DMedicaid
OK200022690AMedicaid
KS200253250AMedicaid
OK200022690AMedicaid