Provider Demographics
NPI:1831265982
Name:MEJO, SUSAN L (ARNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:MEJO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2048
Mailing Address - Fax:360-575-6749
Practice Address - Street 1:600 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3256
Practice Address - Country:US
Practice Address - Phone:360-414-2236
Practice Address - Fax:360-414-2024
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001808103T00000X
WARN00035482163W00000X, 163WP0807X
WAAP30000920363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Not Answered363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8929455OtherCRIME VICTIMS
WA0144976OtherLABOR & IND.
OR292799Medicaid
WA9614116Medicaid
WA0144976OtherLABOR & IND.
R79258Medicare UPIN
OR292799Medicaid