Healthcare Provider Details

I. General information

NPI: 1467934893
Provider Name (Legal Business Name): SUZANNE L WATTS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2018
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 W PERSHING RD STE 200
DECATUR IL
62526-3226
US

IV. Provider business mailing address

544 W PERSHING RD STE 200
DECATUR IL
62526-3226
US

V. Phone/Fax

Practice location:
  • Phone: 217-872-2400
  • Fax: 217-875-4680
Mailing address:
  • Phone: 217-872-2400
  • Fax: 217-875-4680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: