Provider Demographics
NPI:1629034509
Name:EICKERT, SUZANNE (APNP, DC)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:
Last Name:EICKERT
Suffix:
Gender:F
Credentials:APNP, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 HERITAGE RD STE A
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-4017
Mailing Address - Country:US
Mailing Address - Phone:920-347-1990
Mailing Address - Fax:
Practice Address - Street 1:1500 HERITAGE RD STE A
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-4017
Practice Address - Country:US
Practice Address - Phone:920-347-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6239-33363L00000X
WI3298111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400210431OtherMEDICARE ID ASSOCIATED WITH REASSIGNMENT OF BENEFITS
WI38990100Medicaid
WIK400210431OtherMEDICARE ID ASSOCIATED WITH REASSIGNMENT OF BENEFITS