Provider Demographics
NPI:1154555308
Name:GORTON, SUSAN KAY (LPN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:GORTON
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 1:248 BONNIE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9340
Mailing Address - Country:US
Mailing Address - Phone:608-839-4962
Mailing Address - Fax:
Practice Address - Street 1:248 BONNIE RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-9340
Practice Address - Country:US
Practice Address - Phone:608-839-4962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-03
Last Update Date:2009-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25309-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse