Provider Demographics
NPI:1942493879
Name:KANACK, SUZE MARIE
Entity Type:Individual
Prefix:MS
First Name:SUZE
Middle Name:MARIE
Last Name:KANACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-4247
Mailing Address - Country:US
Mailing Address - Phone:307-857-5740
Mailing Address - Fax:
Practice Address - Street 1:207 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4247
Practice Address - Country:US
Practice Address - Phone:307-857-5740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care