Provider Demographics
NPI:1912164047
Name:DAVIS, SUSAN E (RN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:E
Last Name:DAVIS
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:N6716 LAKE LORRAINE RD
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-2503
Mailing Address - Country:US
Mailing Address - Phone:608-883-2176
Mailing Address - Fax:
Practice Address - Street 1:N6716 LAKE LORRAINE RD
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-2503
Practice Address - Country:US
Practice Address - Phone:608-883-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI309441031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35059300Medicaid