Healthcare Provider Details

I. General information

NPI: 1578700522
Provider Name (Legal Business Name): SUE M PARK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE # 19
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE # 19
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-5157
  • Fax: 312-227-9730
Mailing address:
  • Phone: 312-227-5157
  • Fax: 312-227-9730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.007061041.336475
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: