Provider Demographics
NPI:1104813179
Name:PECK, SUSAN D (RN, PHD, GNP-BC)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:D
Last Name:PECK
Suffix:
Gender:F
Credentials:RN, PHD, GNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4808
Mailing Address - Country:US
Mailing Address - Phone:715-829-7325
Mailing Address - Fax:715-895-8573
Practice Address - Street 1:2130 BRACKETT AVE STE B
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4928
Practice Address - Country:US
Practice Address - Phone:715-895-8571
Practice Address - Fax:715-895-8573
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI325-033363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI46-1941568Medicare UPIN