Basic Information
| Provider Information | |||||||||
| NPI: | 1669460010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 S PUBLIC RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800267093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036653036 | ||||||||
| FaxNumber: | 3036653397 | ||||||||
| Practice Location | |||||||||
| Address1: | 1735 S PUBLIC RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800267093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036659310 | ||||||||
| FaxNumber: | 3036653397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | APN.0001242-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | MM0788452 | 01 | DEA | OTHER | 56373848 | 05 | CO | MEDICAID |