Provider Demographics
NPI:1750407383
Name:BADER, SUSAN JEAN (RN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:JEAN
Last Name:BADER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:JEAN
Other - Last Name:BURK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2850 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-1004
Mailing Address - Country:US
Mailing Address - Phone:602-266-5976
Mailing Address - Fax:602-274-8952
Practice Address - Street 1:2850 N 24TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-1004
Practice Address - Country:US
Practice Address - Phone:602-266-5976
Practice Address - Fax:602-274-8952
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99392163WC1500X
AZRN170031163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ042127Medicaid
CO99392OtherLICENSE
AZ936560Medicaid