Provider Demographics
NPI:1124705660
Name:HIBBS, SUSAN CAROL (PMHNP, APRN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:HIBBS
Suffix:
Gender:F
Credentials:PMHNP, APRN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:CAROL
Other - Last Name:HIBBS-SUNDEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, PMHNP
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-672-2691
Mailing Address - Fax:
Practice Address - Street 1:621 W MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-672-2691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10015313363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty