Provider Demographics
NPI:1992711865
Name:MCKINNON, SUSAN HELEN (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HELEN
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3601 W 13 MILE RD
Mailing Address - Street 2:FSC
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6712
Mailing Address - Country:US
Mailing Address - Phone:248-423-2454
Mailing Address - Fax:248-423-2576
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:FSC
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-423-2405
Practice Address - Fax:248-423-2576
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704143131363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500F318190OtherBSBSM
MI4726040Medicaid
MI4726040Medicaid