Healthcare Provider Details

I. General information

NPI: 1275519134
Provider Name (Legal Business Name): SUSAN M HURLBUT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 HUCKLEBERRY AVE
OMRO WI
54963-1851
US

IV. Provider business mailing address

1805 HUCKLEBERRY AVE
OMRO WI
54963-1851
US

V. Phone/Fax

Practice location:
  • Phone: 920-685-7280
  • Fax: 920-303-5630
Mailing address:
  • Phone: 920-685-7280
  • Fax: 920-303-5630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1425
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: