Healthcare Provider Details

I. General information

NPI: 1245671940
Provider Name (Legal Business Name): LORI L SUSDORF RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3552 HWY K EAST
CONOVER WI
54519
US

IV. Provider business mailing address

3552 COUNTY ROAD K
CONOVER WI
54519
US

V. Phone/Fax

Practice location:
  • Phone: 715-479-6699
  • Fax:
Mailing address:
  • Phone: 715-479-6699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number87927-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: