Provider Demographics
NPI:1861165839
Name:NIEBAUM, SUSAN KELLY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KELLY
Last Name:NIEBAUM
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 E KELSEY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4979
Mailing Address - Country:US
Mailing Address - Phone:406-212-2177
Mailing Address - Fax:
Practice Address - Street 1:408 E KELSEY VIEW LN
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-4979
Practice Address - Country:US
Practice Address - Phone:406-212-2177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12585557-4405363LP0808X
MT16869163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent