Provider Demographics
NPI:1881782258
Name:STABO, SUSAN L (FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:STABO
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:LORENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-0160
Mailing Address - Country:US
Mailing Address - Phone:701-477-6111
Mailing Address - Fax:
Practice Address - Street 1:1300 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316-0160
Practice Address - Country:US
Practice Address - Phone:701-477-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR26722363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19807Medicaid
MN717610400Medicaid
NDN716151Medicare PIN
NDN712315Medicare PIN