Provider Demographics
NPI:1801996046
Name:SWENDSEN, SUSAN JANE (CNS, RN, MS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:SWENDSEN
Suffix:
Gender:F
Credentials:CNS, RN, MS
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MODAHL,BARNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 EAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:1401 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2407
Practice Address - Country:US
Practice Address - Phone:218-728-4491
Practice Address - Fax:218-728-4404
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR056479-5364SP0808X, 163WP0808X
MN0209150-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN211525500Medicaid
MN211525500Medicaid