MEDICARE: SUSAN WILDE CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner		IL

General Provider Information

NPI Number	:	1144279100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN WILDE CNP

Provider Business Mailing Address
First Line	:	3707 DOTY RD
Second Line	:	SUITE G
City	:	WOODSTOCK
State	:	IL
Zip	:	60098-7530
Country	:	US
Telephone Number	:	815-206-1067
Fax Number	:	815-206-2804

Provider Business Practice Location Address
First Line	:	4309 W MEDICAL CENTER DR
Second Line	:	B310
City	:	MCHENRY
State	:	IL
Zip	:	60050-8419
Country	:	US
Telephone Number	:	815-344-0900
Fax Number	:	815-344-8957

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	08/31/2007

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