Provider Demographics
NPI:1124432547
Name:GUTIERREZ, SUSAN CAMILLE (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAMILLE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 847692
Mailing Address - Street 2:ATT IPM CREDENTIALING
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7692
Mailing Address - Country:US
Mailing Address - Phone:903-416-1726
Mailing Address - Fax:903-416-1701
Practice Address - Street 1:16620 N US HIGHWAY 281 STE 300
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2679
Practice Address - Country:US
Practice Address - Phone:210-309-1405
Practice Address - Fax:210-688-4596
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125921363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3435414-02Medicaid
TX364816YLINMedicare PIN
TX3435414-02Medicaid
TX364816ZHHLMedicare PIN