Provider Demographics
NPI:1790556579
Name:HENCK, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HENCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:NYSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 W US HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49968-9515
Mailing Address - Country:US
Mailing Address - Phone:906-229-6120
Mailing Address - Fax:906-229-6191
Practice Address - Street 1:103 W US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MI
Practice Address - Zip Code:49968-9515
Practice Address - Country:US
Practice Address - Phone:906-229-6120
Practice Address - Fax:906-229-6191
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker