Provider Demographics
NPI:1699110585
Name:WOLTER, SUSAN K (RN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:WOLTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 CLINIC RD E
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521-8826
Mailing Address - Country:US
Mailing Address - Phone:406-395-4486
Mailing Address - Fax:406-395-4138
Practice Address - Street 1:535 CLINIC RD E
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-8826
Practice Address - Country:US
Practice Address - Phone:406-395-4486
Practice Address - Fax:406-395-4138
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT30264163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse