Healthcare Provider Details

I. General information

NPI: 1285008003
Provider Name (Legal Business Name): SUSAN WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 S DAMEN AVE COLLEGE OF NURSING, DEPT. OF WCFHS (MC 802)
CHICAGO IL
60612-3727
US

IV. Provider business mailing address

2118 HARRISON ST
GLENVIEW IL
60025-4955
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-4321
  • Fax: 312-996-8871
Mailing address:
  • Phone: 847-436-0851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.003797
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: