Provider Demographics
NPI:1740612514
Name:SETIAWAN, SUSAN MILLER (NP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MILLER
Last Name:SETIAWAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12152 COUNTY ROAD 10
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-9694
Mailing Address - Country:US
Mailing Address - Phone:574-825-8792
Mailing Address - Fax:
Practice Address - Street 1:213 MIDDLEBURY ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-2956
Practice Address - Country:US
Practice Address - Phone:574-534-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28129907A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily