Healthcare Provider Details

I. General information

NPI: 1265488936
Provider Name (Legal Business Name): SUSAN LANG CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6708 N KNOXVILLE AVE SUITE 1
PEORIA IL
61614-2862
US

IV. Provider business mailing address

6708 N KNOXVILLE AVE SUITE 1
PEORIA IL
61614-2862
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-6868
  • Fax: 309-691-6858
Mailing address:
  • Phone: 309-691-6868
  • Fax: 309-691-6858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: