Provider Demographics
NPI:1336417997
Name:ZICKLER, SUSAN LEA (APN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEA
Last Name:ZICKLER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 SE 28TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3881
Mailing Address - Country:US
Mailing Address - Phone:479-464-8834
Mailing Address - Fax:479-464-8838
Practice Address - Street 1:103 E CRANDALL AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3629
Practice Address - Country:US
Practice Address - Phone:870-204-6126
Practice Address - Fax:870-204-6264
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily