Healthcare Provider Details

I. General information

NPI: 1912376096
Provider Name (Legal Business Name): SUSAN MICHELLE YACHT APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S CALIFORNIA AVE SUITE 100
CHICAGO IL
60608-2486
US

IV. Provider business mailing address

2707 N CENTRAL PARK AVE APT 3
CHICAGO IL
60647-9480
US

V. Phone/Fax

Practice location:
  • Phone: 773-584-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013324
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: