Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 791-033 | WI |
NPI | 1033170568 |
---|---|
Provider Name | Mrs. Susan H. Pergande |
First Address | Silver Lake, WI 53170-1679 |
Second Address | Kenosha, WI 53142-7884 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2006 |
Last Update Date | 08/07/2007 |