Individual
SUSAN KELLY NIEBAUM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PMHNP-BC
Contact information
Practice address
408 E KELSEY VIEW LN, SOUTH SALT LAKE, UT 84115-4979
(406) 212-2177
Mailing address
408 E KELSEY VIEW LN, SOUTH SALT LAKE, UT 84115-4979
(406) 212-2177
Taxonomy
Speciality
Code
Description
License number
State
163WP0807X
Child & Adolescent Psychiatric/Mental Health Registered Nurse
16869
MT
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
12585557-4405
UT
Other
Enumeration date
07/27/2021
Last updated
02/03/2022
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