Provider Demographics
NPI:1205049582
Name:IPSEN, SUSAN K (APNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:IPSEN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3100
Mailing Address - Country:US
Mailing Address - Phone:920-563-5500
Mailing Address - Fax:920-563-4472
Practice Address - Street 1:1520 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3100
Practice Address - Country:US
Practice Address - Phone:920-563-5500
Practice Address - Fax:920-563-4472
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1760-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00963577DB7792OtherRR MEDICARE
WIIPSENSUSOtherMERCYCARE INSURANCE
WI43968400Medicaid
WI541760264Medicare PIN
WIIPSENSUSOtherMERCYCARE INSURANCE
WIP00963577DB7792OtherRR MEDICARE