Healthcare Provider Details

I. General information

NPI: 1730565870
Provider Name (Legal Business Name): SUSAN WILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3891
  • Fax: 217-788-6459
Mailing address:
  • Phone: 217-788-3891
  • Fax: 217-788-6459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209012987
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number270405
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: