Provider Demographics
NPI:1255960597
Name:ELLISON, SUSAN D (RN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:ELLISON
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 1:5629 STADIUM DR STE D
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1952
Mailing Address - Country:US
Mailing Address - Phone:269-372-5701
Mailing Address - Fax:269-372-5702
Practice Address - Street 1:5629 STADIUM DR STE D
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1952
Practice Address - Country:US
Practice Address - Phone:269-372-5701
Practice Address - Fax:269-372-5702
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI470422171163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care