Healthcare Provider Details

I. General information

NPI: 1003808270
Provider Name (Legal Business Name): SUSAN A MACK APRN-FPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 TEELA LN
DES PLAINES IL
60016-1230
US

IV. Provider business mailing address

514 TEELA LN
DES PLAINES IL
60016-1230
US

V. Phone/Fax

Practice location:
  • Phone: 847-692-6000
  • Fax: 847-692-6112
Mailing address:
  • Phone: 847-692-6000
  • Fax: 847-692-6112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209002933
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277000186
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: