Healthcare Provider Details

I. General information

NPI: 1902848153
Provider Name (Legal Business Name): SUSANNAH NICHOLSON DINTZIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 N WISCONSIN AVE
PEORIA IL
61603-5613
US

IV. Provider business mailing address

2214 N UNIVERSITY ST
PEORIA IL
61604-3221
US

V. Phone/Fax

Practice location:
  • Phone: 309-680-7600
  • Fax: 309-681-4681
Mailing address:
  • Phone: 309-680-7669
  • Fax: 309-681-8443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-002547
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number041283996
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: