1790732626 NPI number — SUSAN G MOURS APNP

Table of content: SUSAN G MOURS APNP (NPI 1790732626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790732626 NPI number — SUSAN G MOURS APNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOURS
Provider First Name:
SUSAN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790732626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W232N7970 NESTING CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUSSEX
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53089-5702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-818-4228
Provider Business Mailing Address Fax Number:
262-653-5412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 WOODLAND PRIME
Provider Second Line Business Practice Location Address:
N74W12501 LEATHERWOOD COURT
Provider Business Practice Location Address City Name:
MENOMONEE FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53051-4490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-777-0811
Provider Business Practice Location Address Fax Number:
414-777-3529
Provider Enumeration Date:
05/27/2006

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: 363LA2200X , with the licence number:  1038 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 1038-033 , 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: 43894500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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