Provider Demographics
NPI:1205020831
Name:GROSS, SUSAN ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ANN
Last Name:GROSS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 SLINGER RD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9356
Mailing Address - Country:US
Mailing Address - Phone:262-644-6240
Mailing Address - Fax:
Practice Address - Street 1:433 SLINGER RD UNIT 1
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086-9356
Practice Address - Country:US
Practice Address - Phone:262-644-6240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39860000Medicaid