Provider Demographics
NPI:1346849395
Name:VANCLEVE, SUE G
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:G
Last Name:VANCLEVE
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 1:10600 W LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-3258
Mailing Address - Country:US
Mailing Address - Phone:414-529-4699
Mailing Address - Fax:414-529-0415
Practice Address - Street 1:10600 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3258
Practice Address - Country:US
Practice Address - Phone:414-529-4699
Practice Address - Fax:414-529-0416
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10137-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist