Basic Information
Provider Information | |||||||||
NPI: | 1639508724 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PIECHOWSKI | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | MELISSA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FORTISI | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: | MELISSA | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | N1798 COUNTY ROAD Z | ||||||||
Address2: |   | ||||||||
City: | WAUTOMA | ||||||||
State: | WI | ||||||||
PostalCode: | 549827300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9206225560 | ||||||||
FaxNumber: | 9206226021 | ||||||||
Practice Location | |||||||||
Address1: | 701 GROVE AVE | ||||||||
Address2: |   | ||||||||
City: | WILD ROSE | ||||||||
State: | WI | ||||||||
PostalCode: | 549846901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9206225560 | ||||||||
FaxNumber: | 9206226021 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2013 | ||||||||
LastUpdateDate: | 11/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5514-33 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.