Provider Demographics
NPI:1639153042
Name:BERNARD, SUSAN MARGARET (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARGARET
Last Name:BERNARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 S 62ND ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-3213
Mailing Address - Country:US
Mailing Address - Phone:414-453-7684
Mailing Address - Fax:414-453-7684
Practice Address - Street 1:1020 S 62ND ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-3213
Practice Address - Country:US
Practice Address - Phone:414-453-7684
Practice Address - Fax:414-453-7684
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30129 031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39990100Medicaid