1619085453 NPI number — MS. SUSAN M STICKNEY CRNA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619085453 NPI number — MS. SUSAN M STICKNEY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STICKNEY
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZINK
Provider Other First Name:
SUSAN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
3

NPI Number Information

NPI Number:
1619085453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3301 W FOREST HOME AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53215-2843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-647-6326
Provider Business Mailing Address Fax Number:
414-671-8860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
855 N WESTHAVEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSHKOSH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54904-7668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-303-8700
Provider Business Practice Location Address Fax Number:
920-303-8789
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  114752-030 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4332200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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