Healthcare Provider Details

I. General information

NPI: 1851640494
Provider Name (Legal Business Name): SUSAN WARD LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 HARRISON AVE
ROCKFORD IL
61108-7631
US

IV. Provider business mailing address

1021 N MULFORD RD
ROCKFORD IL
61107-3877
US

V. Phone/Fax

Practice location:
  • Phone: 815-391-1000
  • Fax: 815-391-5040
Mailing address:
  • Phone: 815-387-5600
  • Fax: 815-391-5041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043-105257
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: