Provider Demographics
NPI:1578587598
Name:CONLEY, C. SUE (MD)
Entity Type:Individual
Prefix:
First Name:C.
Middle Name:SUE
Last Name:CONLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 MCMILLEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1996
Mailing Address - Country:US
Mailing Address - Phone:920-568-1000
Mailing Address - Fax:920-563-0258
Practice Address - Street 1:426 MCMILLEN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1996
Practice Address - Country:US
Practice Address - Phone:920-568-1000
Practice Address - Fax:920-563-0258
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33479 020207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32137000Medicaid
WI32137000Medicaid