Provider Demographics
NPI:1861090219
Name:WILBRECHT, SUZANNE MOORE (CNM)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MOORE
Last Name:WILBRECHT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 S 2ND E STE 200
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1906
Mailing Address - Country:US
Mailing Address - Phone:208-356-0234
Mailing Address - Fax:208-656-8877
Practice Address - Street 1:37 S 2ND E STE 200
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1906
Practice Address - Country:US
Practice Address - Phone:208-356-0234
Practice Address - Fax:208-656-8877
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2021-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61139099363LX0001X
ID66117367A00000X
WAN361143735367A00000X
WAAP61139097367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID66117OtherIDAHO STATE BOARD OF NURSING
WA2174476Medicaid