Provider Demographics
NPI:1841679388
Name:LUNDELL, SUSAN MAE (FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MAE
Last Name:LUNDELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-2212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-2212
Practice Address - Country:US
Practice Address - Phone:920-215-1887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128187363LF0000X
MO2019015269363LF0000X
OK218196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX441558YNGSMedicare PIN
TX441558YL7AMedicare PIN
TX441558YL7BMedicare PIN