Provider Demographics
NPI:1619085453
Name:STICKNEY, SUSAN M (CRNA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:STICKNEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:ZINK
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7668
Practice Address - Country:US
Practice Address - Phone:920-303-8700
Practice Address - Fax:920-303-8789
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI114752-030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4332200Medicaid
WI4332200Medicaid