Provider Demographics
NPI:1841591476
Name:KOGER, SUSAN MARIE (NP)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:MARIE
Last Name:KOGER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:HAVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HAVEN
Mailing Address - Street 1:4706 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1514
Mailing Address - Country:US
Mailing Address - Phone:248-310-1270
Mailing Address - Fax:
Practice Address - Street 1:1615 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7984
Practice Address - Country:US
Practice Address - Phone:231-745-4624
Practice Address - Fax:231-745-5031
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-12
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704139637363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner