Healthcare Provider Details

I. General information

NPI: 1437172079
Provider Name (Legal Business Name): SUSAN E MASSEY CNM, WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 VETERANS MEMORIAL DR
MOUNT VERNON IL
62864-5951
US

IV. Provider business mailing address

3130 VETERANS MEMORIAL DR
MOUNT VERNON IL
62864-5951
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5266
  • Fax: 833-431-2272
Mailing address:
  • Phone: 618-997-5266
  • Fax: 833-431-2272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number131902
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209-000556
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number131902
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209-000554
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: