Basic Information
| Provider Information | |||||||||
| NPI: | 1114193885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NULTY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | DEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6735 W BRADLEY RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532233325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143543300 | ||||||||
| FaxNumber: | 4143547419 | ||||||||
| Practice Location | |||||||||
| Address1: | 6735 W BRADLEY RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532233325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143543300 | ||||||||
| FaxNumber: | 4143547419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2008 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 595019 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 40044400 | 05 | WI | MEDICAID |