Provider Demographics
NPI:1275519134
Name:HURLBUT, SUSAN M (NP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:HURLBUT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1805 HUCKLEBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-1851
Mailing Address - Country:US
Mailing Address - Phone:920-685-7280
Mailing Address - Fax:920-303-5630
Practice Address - Street 1:1805 HUCKLEBERRY AVE
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-1851
Practice Address - Country:US
Practice Address - Phone:920-685-7280
Practice Address - Fax:920-303-5630
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1425363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43994400Medicaid