Provider Demographics
NPI:1619398633
Name:HAINES, SUZANNE B (NP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:B
Last Name:HAINES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 SUNRISE CT
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1261
Mailing Address - Country:US
Mailing Address - Phone:920-288-9021
Mailing Address - Fax:
Practice Address - Street 1:138 SUNRISE CT
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1261
Practice Address - Country:US
Practice Address - Phone:920-288-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5627-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN41200031Medicare Oscar/Certification
WIK400118039Medicare Oscar/Certification