Provider Demographics
NPI:1801094594
Name:BENDER, SUSAN M (RN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:BENDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:BOWEN-BENDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:4251 FOREST PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2810
Mailing Address - Country:US
Mailing Address - Phone:314-531-7526
Mailing Address - Fax:314-531-3190
Practice Address - Street 1:4251 FOREST PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2810
Practice Address - Country:US
Practice Address - Phone:314-531-7526
Practice Address - Fax:314-531-3190
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO127042363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420766107Medicaid