Provider Demographics
NPI:1366071268
Name:HIESTAND, SUSAN LYNN (FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:HIESTAND
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 1:4368 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-9595
Mailing Address - Country:US
Mailing Address - Phone:269-983-6501
Mailing Address - Fax:269-983-2237
Practice Address - Street 1:4025 HEALTH PARK LN
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3421
Practice Address - Country:US
Practice Address - Phone:269-429-7100
Practice Address - Fax:269-429-1959
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704290955363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner