Healthcare Provider Details

I. General information

NPI: 1104845833
Provider Name (Legal Business Name): SUSAN M. GIACCHINO APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W COURT ST SUITE 108
KANKAKEE IL
60901-3664
US

IV. Provider business mailing address

901 MCCLINTOCK DR SUITE 202
BURR RIDGE IL
60527-0871
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-2015
  • Fax:
Mailing address:
  • Phone: 888-220-6432
  • Fax: 630-654-4253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License Number209-002386
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: