Provider Demographics
NPI:1053526475
Name:MICHELSON, SUSANNE ELISABETH
Entity type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:ELISABETH
Last Name:MICHELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4661 N PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53225-4447
Mailing Address - Country:US
Mailing Address - Phone:414-464-9785
Mailing Address - Fax:
Practice Address - Street 1:4661 N PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53225-4447
Practice Address - Country:US
Practice Address - Phone:414-464-9785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49287 - 030163W00000X
WI49287-030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35026900Medicaid