Healthcare Provider Details

I. General information

NPI: 1922004332
Provider Name (Legal Business Name): SUSAN ADAMS RN, APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E JACKSON ST
MACOMB IL
61455-2530
US

IV. Provider business mailing address

PO BOX 1179
MACOMB IL
61455-5579
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-4101
  • Fax:
Mailing address:
  • Phone: 309-833-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209004534
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: