Provider Demographics
NPI:1316087679
Name:BROWN, SUSAN D (LPN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:BROWN
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 1:508 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-2017
Mailing Address - Country:US
Mailing Address - Phone:608-742-1883
Mailing Address - Fax:
Practice Address - Street 1:3113 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4330
Practice Address - Country:US
Practice Address - Phone:608-242-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14260031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV14260031OtherLPN LICENSE NUMBER
WI42016400Medicaid