Provider Demographics
NPI:1992224513
Name:LILJENSTOLPE, SUSANNA LOCKWOOD (FNP)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:LOCKWOOD
Last Name:LILJENSTOLPE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12361 W BOLA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85378-9021
Mailing Address - Country:US
Mailing Address - Phone:602-698-7325
Mailing Address - Fax:480-500-8430
Practice Address - Street 1:12361 W BOLA DR STE 100
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:602-698-7325
Practice Address - Fax:480-500-8430
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ265155363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRN170752OtherLICENSE