Healthcare Provider Details

I. General information

NPI: 1356974786
Provider Name (Legal Business Name): SUSAN GWODZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 02/09/2022
Certification Date: 01/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

24812 FIELDBROOK DR
PLAINFIELD IL
60544-2876
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone: 815-616-0501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number041.305772
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209024181
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: