Provider Demographics
NPI:1427068790
Name:DUNHAM, SUE ELLEN (FNP)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ELLEN
Last Name:DUNHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 BAY RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2433
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:989-791-1392
Practice Address - Street 1:4020 COPPER VW STE 104
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-421-6921
Practice Address - Fax:231-421-7852
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704082241363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4945609-10Medicaid
MI5008770670OtherBLUE CROSS BLUE SHIELD
MI4945609-10Medicaid
MI5008770670OtherBLUE CROSS BLUE SHIELD