Healthcare Provider Details

I. General information

NPI: 1134531114
Provider Name (Legal Business Name): SUSAN DE GRAAF R.N. B.S.N. C.L.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 CENTER AVE
OOSTBURG WI
53070-1349
US

IV. Provider business mailing address

1112 CENTER AVE
OOSTBURG WI
53070-1349
US

V. Phone/Fax

Practice location:
  • Phone: 414-218-3650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number96673-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: