Healthcare Provider Details

I. General information

NPI: 1447566435
Provider Name (Legal Business Name): SUE S MCGINNES APN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 FRANKLIN AVE
NORMAL IL
61761-3510
US

IV. Provider business mailing address

17419 OLD COLONIAL RD
BLOOMINGTON IL
61705-5920
US

V. Phone/Fax

Practice location:
  • Phone: 309-888-5531
  • Fax: 309-888-5530
Mailing address:
  • Phone: 309-662-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209001665
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: