Provider Demographics
NPI:1811043458
Name:LARSON, SUE A (RN)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:A
Last Name:LARSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N MAYFAIR RD
Mailing Address - Street 2:SUITE 901
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1309
Mailing Address - Country:US
Mailing Address - Phone:414-774-3484
Mailing Address - Fax:414-778-3446
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:SUITE 901
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1309
Practice Address - Country:US
Practice Address - Phone:414-774-3484
Practice Address - Fax:414-778-3446
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse