Provider Demographics
NPI:1255602504
Name:MORTIMER, SUSAN MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:MORTIMER
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 1:22261 REED RD
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:OH
Mailing Address - Zip Code:44822-9207
Mailing Address - Country:US
Mailing Address - Phone:740-599-7639
Mailing Address - Fax:740-599-7639
Practice Address - Street 1:22261 REED RD
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:OH
Practice Address - Zip Code:44822-9207
Practice Address - Country:US
Practice Address - Phone:740-599-7639
Practice Address - Fax:740-599-7639
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH042884-MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse