Provider Demographics
NPI:1164065025
Name:JANZ, SUSAN JANE
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:JANZ
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 1:1014 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-5986
Mailing Address - Country:US
Mailing Address - Phone:715-848-6288
Mailing Address - Fax:
Practice Address - Street 1:1014 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-5986
Practice Address - Country:US
Practice Address - Phone:715-848-6288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103294-82174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist