Provider Demographics
NPI:1972601854
Name:PERRY, SUSAN C (LPN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:C
Last Name:PERRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18249 MATTHEWS ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7481
Mailing Address - Country:US
Mailing Address - Phone:734-284-6688
Mailing Address - Fax:734-284-6688
Practice Address - Street 1:18249 MATTHEWS ST
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7481
Practice Address - Country:US
Practice Address - Phone:734-284-6688
Practice Address - Fax:734-284-6688
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703056697164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4701443Medicaid