Basic Information
| Provider Information | |||||||||
| NPI: | 1902184773 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | SUSANNAH | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077950111 | ||||||||
| FaxNumber: | 2077537201 | ||||||||
| Practice Location | |||||||||
| Address1: | 2577 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813015919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702478382 | ||||||||
| FaxNumber: | 9702594403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2011 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | CNP111056 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | C-APN.0003259-C-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.