Provider Demographics
NPI:1053419820
Name:BOBO, SUSAN D
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:BOBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4128
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39304-4128
Mailing Address - Country:US
Mailing Address - Phone:601-581-8482
Mailing Address - Fax:601-483-5543
Practice Address - Street 1:1818 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-5429
Practice Address - Country:US
Practice Address - Phone:601-581-8482
Practice Address - Fax:601-483-5543
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR802552363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07526012Medicaid
MS500002368Medicare PIN