Basic Information
| Provider Information | |||||||||
| NPI: | 1871248179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAQUE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 CARGO CT | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402991938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008056989 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 CARGO CT | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402991938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008056989 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2022 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | 1082389 | KY | Y | Other Service Providers | Military Health Care Provider |
No ID Information.