Individual
SUSAN SAMPLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
700 N WESTHAVEN DR, OSHKOSH, WI 54904
(920) 456-2030
(920) 456-2025
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(800) 326-2250
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
7300
WI
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
7300-33
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100062248
—
WI
05
—
100063103
—
WI
Enumeration date
09/29/2016
Last updated
11/21/2025
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