Healthcare Provider Details

I. General information

NPI: 1760923221
Provider Name (Legal Business Name): SUSAN LYNN CONN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17321 STATE ROAD 23
SOUTH BEND IN
46635-1531
US

IV. Provider business mailing address

707 CEDAR ST STE 200
SOUTH BEND IN
46617-2057
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-8400
  • Fax: 574-335-0796
Mailing address:
  • Phone: 574-335-8700
  • Fax: 574-335-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28128994A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28128994A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: