Provider Demographics
NPI:1982920013
Name:SUSBERRY, CHANTA (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:CHANTA
Middle Name:
Last Name:SUSBERRY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 N. 91ST STREET
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1649
Mailing Address - Country:US
Mailing Address - Phone:414-393-1389
Mailing Address - Fax:
Practice Address - Street 1:4142 N 91ST STREET
Practice Address - Street 2:APARTMENT 2
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1649
Practice Address - Country:US
Practice Address - Phone:414-393-1389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI144593030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse