Provider Demographics
NPI:1740368786
Name:SMALL, SUSAN V (ARNP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:V
Last Name:SMALL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:V
Other - Last Name:BOWEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:703 S WHITMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ROSALIA
Mailing Address - State:WA
Mailing Address - Zip Code:99170
Mailing Address - Country:US
Mailing Address - Phone:509-523-4950
Mailing Address - Fax:509-523-4951
Practice Address - Street 1:703 S WHITMAN AVE
Practice Address - Street 2:
Practice Address - City:ROSALIA
Practice Address - State:WA
Practice Address - Zip Code:99170
Practice Address - Country:US
Practice Address - Phone:509-523-4950
Practice Address - Fax:509-523-4951
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9652371Medicaid
WA9652371Medicaid
WA8864235Medicare PIN