Provider Demographics
NPI:1811620776
Name:JOHNSON, SUSAN MARY (RN BSN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMS BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53191-9709
Mailing Address - Country:US
Mailing Address - Phone:262-581-6737
Mailing Address - Fax:
Practice Address - Street 1:139 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:WILLIAMS BAY
Practice Address - State:WI
Practice Address - Zip Code:53191-9709
Practice Address - Country:US
Practice Address - Phone:262-581-6737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171930-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse