Provider Demographics
NPI:1982922050
Name:O'MALLEY-LARSON, SUSAN ANN (LPN)
Entity Type:Individual
Prefix:MR
First Name:SUSAN
Middle Name:ANN
Last Name:O'MALLEY-LARSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:CALTEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2075 LOWER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-9674
Mailing Address - Country:US
Mailing Address - Phone:262-284-0389
Mailing Address - Fax:
Practice Address - Street 1:2075 LOWER RIDGE RD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-9674
Practice Address - Country:US
Practice Address - Phone:262-284-0389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI309598-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse