Provider Demographics
NPI:1962522573
Name:BALLINGHAM, SUZANNE (FNP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:BALLINGHAM
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 1:3955 HARRISON BLVD
Mailing Address - Street 2:L-1
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2313
Mailing Address - Country:US
Mailing Address - Phone:801-621-1701
Mailing Address - Fax:801-393-9411
Practice Address - Street 1:3955 HARRISON BLVD
Practice Address - Street 2:L-1
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2313
Practice Address - Country:US
Practice Address - Phone:801-621-1701
Practice Address - Fax:801-393-9411
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2181564405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner