=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356008668
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN E SELTHOFNER DNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2021
-----------------------------------------------------
Last Update Date | 03/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11101 W LINCOLN AVE
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-1133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-767-4411
-----------------------------------------------------
Fax | 414-328-3708
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1511 GREEN TREE RD
-----------------------------------------------------
City | WEST BEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53090-1755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-283-0448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 11839
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------