Provider Demographics
NPI:1548474208
Name:SUISTE, PATRICIA DIANE (LPN)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DIANE
Last Name:SUISTE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2168
Mailing Address - Country:US
Mailing Address - Phone:906-228-9699
Mailing Address - Fax:906-485-1150
Practice Address - Street 1:97 S 4TH ST
Practice Address - Street 2:
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-2168
Practice Address - Country:US
Practice Address - Phone:906-228-9699
Practice Address - Fax:906-485-1150
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI304675031164W00000X
MI4703079462164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42023100Medicaid