Provider Demographics
NPI:1679536395
Name:ELLIOTT, SUSAN CORENE (LPN)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:CORENE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 MARINERS CIR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4565
Mailing Address - Country:US
Mailing Address - Phone:262-567-7735
Mailing Address - Fax:
Practice Address - Street 1:4350 MARINERS CIR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4565
Practice Address - Country:US
Practice Address - Phone:262-567-7735
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22726-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse