1285616292 NPI number — SUSAN C RALSTON RN MSN ARNP

Table of content: SUSAN C RALSTON RN MSN ARNP (NPI 1285616292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285616292 NPI number — SUSAN C RALSTON RN MSN ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RALSTON
Provider First Name:
SUSAN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN MSN ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285616292
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13640 N PLAZA DEL RIO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85381-4846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-876-3800
Provider Business Mailing Address Fax Number:
623-523-6586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9165 W THUNDERBIRD RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-4847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-523-6555
Provider Business Practice Location Address Fax Number:
623-523-6586
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  RN133535 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 959588 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: RN133535 . This is a "ST LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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