Provider Demographics
NPI:1255708350
Name:WADE, SUSAN (RN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12440 MAC ALISTER WAY UNIT 107
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-8326
Mailing Address - Country:US
Mailing Address - Phone:919-357-3028
Mailing Address - Fax:
Practice Address - Street 1:12440 MAC ALISTER WAY UNIT 107
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-8326
Practice Address - Country:US
Practice Address - Phone:919-357-3028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73131-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse